Modern Language Studies Abroad (MLSA) & San Diego Mesa College
IMPORTANT INSTRUCTIONS: (1) Download and print this form. (2) Provide all the information in the application below; (3) Sign the “Release and
Agreement” form; (4) Enclose a $100 regis
tration fee payable to MLSA; (5) Attach two passport-size recent head shot photos in color,
(minimumfine” quality portrait) to your application; (6) Mail application m
aterials to:
P.O. Box 548, Frankfort, IL 60423.
(7) Email the program coordinators at mes with this text:I enrolled with MLSA. I will take (the class you plan to take)”
Dora Schoenbrun-Fernandez,, Office G-237, 619-388-2228.
For program payment information, contact Dr. Celestino Ruiz at (815) 464
-1800. Email:
Full Name Date
Mailing Address
Street City State Zip
Home Phone (_____)______________Cell Phone (_____)_____________Work Phone (_____)_________________
Email (Important! This is our primary means of contact with you.)
Alternate Email
Date of birth _____/_____/_____ Age _____ Sex M ___ F___ Citizenship: USA ____ Other
Passport # (send later if unavailable) Driver's License # or student I.D.
Course I Plan on taking: SPAN 102 SPAN 201
Name Relationship
Home Phone Cell Phone Work Phone
Street City State Zip
1. Is the applicant in good physical and mental health? Yes ___ No ___
2. Has t
he applicant ever required mental health care? Yes ___ No ___
3. Is the applicant under medical treatment? Yes ___ No ___
4. Do you have any allergies or require special medical attention that may affect your travels? Yes ___ No ___
5. Do you require special assistance? Yes ___ No ___
6. Do you smoke? Yes ___ No ___
If you wish to disclose any information relevant to your mental or physical health, diet, allergies, current medications, or any other
information you feel may affect your travels please attach a separate document or e-mail MLSA.
While not required, it is advisable that health concerns, both m
ental and physical, be disclosed to MLSA at the time of application. The
disclosure of this information will not result in our denying a
sion to any student, but will allow MLSA to prepare and/or provide
information relevant to his/her selected program in a timely manner. Disability services vary by program, university, and country, thus
MLSA cannot guarantee that all services offered at a participant's home university can be matched abroad. Efforts are made to provide
special accommodations, within reason. However, differences in disability services can be significant from one country or city to another,
and it is beneficial to all involved if students are fully advised of services in advance. The differences in disabilities services within a
particular city or host university will not be grounds for grade contestation or exceptions to our cancellation policies.
(Not Required.)
University (if other than SDCC):
San Jose, Costa Rica - January 2018
Select Courses: 210 Conversation I (102 pre-req)
[or] 211 Conversation II (210 pre-req)
[and/or] Biology 180 Each class is worth 3 credits.
Geology 100
Modern Language Studies Abroad (MLSA) & San Diego Mesa College
I, __________________________________, an applicant for the study program sponsored by Modern Language Studies Abroad (hereby
referred as MLSA) agree to the following understanding, binding upon myself. I acknowledge that I am not under 18 years of age.
I, the undersigned, acknowledge that MLSA, its employees and agents, San Diego Mesa College, the San Diego Community
College District, my professors in this country and overseas are not responsible for damages or other liability in connection with
the program, or for events beyond their control such as (without limitations) strikes, war, terrorism, loss or theft of personal
belongings, delays, weather, acts of God, or government regulations and restrictions; or hotels, restaurants, and other suppliers of
program services. I agree to release MLSA, its agents and employees, my local school, the teachers, counselors, directors, and
host universities overseas from all claims arising out of such events, acts or omissions.
I understand that neither MLSA nor San Diego Mesa College can be held responsible for my health, safety and well-being during stay-
ahead/behind periods, when I am absent from supervised activities or if I fail to follow the directions of the directors of the program. If I
become ill or incapacitated MLSA will assist a student in case of an emergency. I grant MLSA, its personnel or university teachers at their
discretion to place me, at my own expense, in a hospital at any point for any services and treatment, or if no hospital is available, to place
me in the hands of a local medical doctor for treatment. MLSA and its personnel are further authorized to fly me back to the United States at
my expense for medical treatment, if this is deemed necessary by MLSA in consultation with local medical authorities.
I agree to abide by the Participant's Behavior regulations and I understand that MLSA has full authority to terminate
participants in its programs and reserves the right to enforce group rules and standards of conduct explained in the
brochures and literature. I understand that my failure or refusal to comply with such rules may entail my termination as a
participant and my return home at my own or my parents' expense and that I will have no right to refund of any part of my
program fees. I will indemnify MLSA, its employees and agents for any financial liability or obligation which I personally
incur, or injury, or damage to the person or property of others which I cause, while participating in the MLSA program.
MLSA is the principal agent and is responsible to participants in making arrangements for all services and accommodations
included in the program. MLSA shall not be responsible if airlines, restaurants, ground transportation companies and other
suppliers of arrangements fail to provide their service or accommodations exactly as set forth in the program literature.
In addition, I understand that MLSA's program prices are based on currently, ground transportation rates, hotel, residences
and home stay rates, tuition rates, applicable government taxes, government regulations and currency exchange rates in
effect at the time of printing the brochure and are subject to change depending on the tariffs, regulations and rates. I agree
that MLSA reserves the right to increase the price of any program by the amount of an increase in its costs. I agree to pay
such increased fees and shall not be entitled to cancel my reservations from the program without penalties as set forth in the
cancellation and refund section of this agreement and receive a refund solely on this ground.
I agree that any film likeness taken of me while participating in the MLSA program and any of my comments or statements
may be used in future materials published by MLSA.
I understand that I am responsible to obtain the required documentation, including passports, visas and health certificates.
My failure to do so will not entitle me to any refund.
I understand that if I wish to cancel my reservation in the program, I must to do so in writing to MLSA - P.O. Box 548, Frankfort, IL
60423. Verbal cancellations will not be honored. The postmark of the USA Postal Service will be the effective determining date for
all cancellations. I accept the terms of the Refund Policy as outlined here. If a participant withdraws more than 60 days before
leaving he/she receives full refund, less $400; if he/she withdraws 59 to 30 days before departure he/she receives partial refund, but
the amount withheld will be a minimum of $900; 29 days or less prior to departure, participants will be refunded 20% of total cost
less $100 non-refundable Registration Fee. Once the trip has begun, NO REFUNDS WILL BE MADE UNDER ANY
CIRCUMSTANCES FOR ANY REASON for unused accommodations, meals, land transportation, excursions, hotels or other
activities. No reduction or refunds will be made from services omitted by me and no substitutions will be
allowed for services not used. Services cannot be transferred to another person. We recommend the purchase of
Trip Cancellation Insurance. We can supply you with forms and suggested companies.
I agree to forward payments by dates due. A service charge of $200 per person will be assessed to students joining the
program after April 10 or participants who fall behind in their payment schedule. Students enrolling less than 75 days
before departure must send full payment with the application.
I certify that I have read in full the RELEASE AND AGREEMENT and agree that all terms and conditions stated therein are
fully incorporated in this agreement. I agree to be bound hereby, and to comply therewith. I further understand that this
agreement will be effective only upon my acceptance by MLSA and San Diego Mesa College as a participant in the
program, and shall be governed by the laws of the states of Illinois and California.
Signature of the Applicant __________________________________________
Dec. 3
after December 3.
, the
payment deadline
click to sign
click to edit