French-American Exchange - Immersion Weekend Registration Form


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Immersion Weekend Registration Form

Last Name

First Name

Home Address:

Street

City

State

Zip

Home Phone

Work Phone

E-mail

Fax

Profession

How did you find out about our programs?

Reason for attending this program: Personal Professional

Preferred dates:

First choice:
Second choice:

Desired Accommodation:
Double occupancy with shared bath ($295)
Private room with shared bath ($325)
Private room with private bath ($355)

Knowledge of French

Elementary

Low intermediate

High intermediate

Advanced

When did you last take a French course?

Where? Duration of course:

Have you ever traveled to a French-speaking country? Yes No

If yes, where and for how long?

Hobbies and interests:

I agree that the above information I have provided is true to the best of my knowledge.

Payment by credit card. Please charge $ to my credit card.

Card holder name

Credit card number:

Expiration date:

Credit card type

I understand and agree that the French-American Exchange may not be held liable in any way for any occurrence in connection with my participation in the French Immersion Weekend Retreat which may result in injury or other damages to me or my family. I hereby personally assume all risks related to this program.

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Comments, questions? Send them to info@FrenchAmericanExchange.com