General Information Participant desires to take part in the following program at CEHS. All program participants must be at least 18 years of age. "*" indicates required fields Sex (optional)MaleFemale U.S. Citizen?*YesNo Program of Interest*SpringSpring 90-dayMaySummer 1Summer 2FallInternship Use home address in case of an emergency?YesNo If No, write emergency address here: Your date of birth* High School/College/University you are now attending: I am aSeniorJuniorSoph.Freshman Do you have a current passport?YesNo Do you have a medical condition or illness? If so, please explain. This information is confidential. Applicant’s signature / name: Date: By including my name and date I hereby certify that all the information I have provided on this application form are correct. I have read and accept the privacy policy. I wish to receive additional information about the CEHS and the program I have selected. In accordance with the established Organic Law 15/1999 for the Protection of Personal Data, the information collected in this document is included in an automated processing file belonging to Richard Crescenzo D’Augusta (Tax I.D. # X2676498B), trade name (CEHS), in compliance with the security measures required by law, for the purposes that are clear from this document; the user reserves the right to access, rectification, erasure or objection by means of a written petition, together with a copy of a valid I.D. card, to the following address: C/San Valentín, 12, Entresuelo A, 40003, Segovia, España.
