Student Enrollment Form

You need to fill out the following form prior purchasing any of our class packages.
We will personally contact you in the next 1 or 2 business days in order to arrange your class schedule.
You may also call to our office at 646-233-4235 to speak directly with an Easy Español representative at any time.
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Fields mark with (*) are mandatory
*UserId     What is this ?
*Password   What is this ?
*First name  
Middle Name
*Last Name  
Company Name
Present Occupation
Home Address
City
State
Zip  
Country  
*Phone    
(xxx-xxx-xxxx)
Cell  
*E-mail    
How would you rate your general language proficiency in Spanish?
No background at all
Elementary
Intermediate
Advanced
Other
 Choose the program of your interest :
 * The cost of these programs varies according to the length and intensity of the program
Choose the type of accommodation 
Additional Information
Do you have any special diet ?
Do you have any illness related to lodging conditions ?
Any additional information that may help us make your staying more enjoyable ?
Arrival Information
Date & time of Arrival for Accomodation (MM/DD/YYYY)
Hora/Time   
Aerolínea / Airline and flight number
Date of Departure (MM/DD/YYYY)
Hora/Time