Name (As printed in your passport):* Preferred name (if different):* Gender* Age:* Permanent Address:* Zip Code:* City:* State/Province:* Country:* E-mail:* Name and dates of programs for which you are registering (if applicable):* Regular Program (all year-round) Winter Women and Social Change in Mexico Winter LGBTQ Program Language and Culture for Educators Summer LGBTQ Program Summer Women and Social Change in Mexico Medicine in Mexico: Prehispanic, Institutional, Alternative Spanish Language for Ministry Winter of Dreams Abroad Others… Enter other… Tell us about your studies/the work you do:* When will you arrive in MEXICO City (Date, Approximate Hour)*When will you arrive in MEXICO City (Date, Approximate Hour)*: Fecha When will you arrive in MEXICO City (Date, Approximate Hour)*: Hora How did you learn about CILAC FREIRE?*- Seleccionar -Friend/AcquaintanceAdvertisementPosted informationInforamtion mailed to me/ my organizaion Date of birth:*Date of birth:*: AñoAño1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Date of birth:*: MesMesEneFebMarAbrMayJunJulAgoSepOctNovDic Date of birth:*: DíaDía12345678910111213141516171819202122232425262728293031 Telephone number (home):* Telephone number (work):* School you currently attend/ Organization where you currently work:* Have you studied Spanish before?* Yes No Where? How long?*- Seleccionar -Never1 - 2 semesters3 - 4 semesters5 or more What languages do you speak?* English German Italian French Spanish (partially) Others, please specify When would you like to start classes and how long do you plan to study?* Tell Us more* Lodging: (if Special program, included in program cost)*- Seleccionar -Private Room: U.S $35 daily What type of housing would you like?* Mexican Family (all CILAC FREIRE families are LGBT friendly.) Apartment Otros... Enter other… Any special needs?* Vegetarian diet Vegan diet No dairy products Dairy product ok No smoking No pets Allergies Accessibility Bed size If you check allergies, accessibility or bed size, please specify* What are your special interests?* History Economics Women/Gender Issues Education Ministry Health/Healthcare Politics Arts (please specify) Ecology Indigenous Cultures/Issues Otros... Enter other… What are your objectives in participating at CILAC FREIRE?* Do you plan to continue traveling after your studies at CILAC Freire?* Where? As preparation for this program, please begin to reflect on your experience/ your learning from previous cultural encounters:* What experience have you had interacting/what is your relationship with the people of Mexico or other Latin American countries?* What have you learned from that experience about Latino/Latin American culture and your culture/ yourself?*
