+52 449 500 0410 soporte@utr.edu.mx

Program Information

Program Name: Mexican Summer Spanish Immersion
Session: July  2017

Universidad Tecnológica El Retoño will not use the applicants’ personal information for any purpose other than related to this program.

1. Personal Information

First name /Middle Name
Family Name
Date of birth (day-month-year):
Nationality
Passport Number
Gender:
E-mail (We will be using this, please check it regularly):*
Confirm E-mail:*
Permanent Address:
Phone (Include the country code,area code, phone number):
Native language:
Other Languages 1:
Language 1, Please Check:
Other Languages 2:
Language 2, Please Check:
Other Languages 3:
Language 3, Please Check:
How did you hear about the summer program?


Documents that should accompany this application

Upload a photo:
Academic qualifications/Transcript:
Photocopy of the main page of your passport:
Copy of international health insurance coverage:
2 recommendation letters from your home university or community college:

2. Academic Information

Home Institution:
Country:
Choice:
Name of the program you are enrolled in:
Year of study:
Have you ever studied Spanish?
For how long?
This will be my first experience with Spanish

Spanish proficiency level:

Speaking
Listening:
Reading
Writing:
Department to contact for academic inquiries:
Person to contact for academic inquiries:
Telephone number :
E-mail:

3. Medical Information

All information hereby disclosed will be confidential. It will be stored as your medical record at the UTR, in case you need medical attention, and will not in any way affect your status at UTR.

Name of insurance company:
Insurance carrier policy number:
Blood type:

4. Emergency contact

Name:
Relationship:
Emergency contact address:
Phone (Include contry code, area code, phone number)
Mobile phone (Include contry code, area code, phone number)

5. Clinical Record

Do you have any type of allegies?
Penicillin:
Sulfa:
Drugs:
Salicylic Acid:
Other:
Has your physical activity been restricted within the past five years?
Give reasons and length of the restriction:
Are you currently taking any medication?
Explain reasons and dosage:
Do you suffer from any emotional or physical medical condition? This knowledge will help us treat you appropiately in case of emergency.
Explain:
Please add any important information about your health that you consider might be relevant to us:

6. Accommodation

About accommodation:
Choose an option:
Contact name:
Contact address
Phone number:
Is there any important information for Universidad Tecnológica el Retoño to know (medical conditions, allergies, physical/mental disabilities, religion, personal habits, etc), before you participate in this program?

When you declare about your health problem etc, submission of a health certificate may be required.

7. Responsability of Information & Payment

On submission of this form and required documents, you will receive confirmation email. We ask for a deposit fee of €100 / $100 USD non-refundable . This deposit will be deducted from the total amount of your course and accommodation fees. Fees are expected to be paid one week before the start date of the program. If you require further information prior to submitting an application, please contact: Maria Antonieta Medina at maria.medina@utr.edu.mx or +52 (449) 500 0410.

Terms and Conditions:



As a participant of the “Mexican Summer Spanish Immersion 2017” (referred to as “program” from now on), I hereby state that:

  • I will conduct myself properly as a program participant.

  • I will follow the instructions given to me by the UTR staff and the program coordinators and will not violate any law, regulation or public policy in Mexico.

  • I will make restitution for any damages or injury caused to UTR or others, intentionally or accidentally.

  • I will not hold UTR responsible, monetarily or otherwise, should I cause an accident or become ill by my own negligence or in circumstances that are out of UTR’s control.


  • Do you accept the trust agreement above?



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