Registration form

Registration form

Please, click here to download a MS Word version of the registration form/Por favor haz click aquí para descargar una versión en MS Word de la ficha de pre-inscripción. Send it as an attachment to immersion@uvigo.es. Remítenosla como adjunto a immersion@uvigo.es.

Your photo (optional)
Personal details
Title (as shown on Passport): Mr/Mrs/Miss/Ms
Family name:
Given name/s:
Gender:
Date of Birth:		_ _ / _ _ / _ _ _ _ Day/Month/Year
Country of Birth:
DNI:
Address for all correspondence
Street:
Town/City:
Country:
Postcode:
Telephone:
Mobile:
Fax:
Email:
Home address (if different from above)
Street:
Town/City:
Country:
Postcode:
Educational background
How many years have you studied English? :
Level of English:	Elementary:
	Pre-Intermediate:
	Intermediate:
	Upper-Intermediate:
	Advanced:
English language program selection
Course name:
Program start date:		_ _ / _ _ / _ _ _ _ Day/Month/Year
Accommodation
Single bedroom:
Double bedroom:
Twin bedroom:
I am going to share a room with (name of the person):
I am willing to share a room with any other participant on the course:
Food
List any special dietary requirements:
Medical information
Any relevant medical information:
Publicity regarding the immersion program
How did you find out about the immersion program? :
Application form		Return this form to: immersion@uvigo.es