WIP Enrollment Form
March 2 - 3, 2019

First Name:*

Middle Initial:

Last Name:*

Date of Birth (use format mm/dd/yyyy):*

Street Address: *

Street Address 2:

City: *

State: *

Zip: *

Country:*

Home Phone:*

Work Phone:

Cell Phone:

E-mail: *

Organization:

Occupation:

If yes, please specify:

If yes, please specify:

If yes, please specify:

How did you hear about the Rassias Center?*
-Select One- Word of Mouth Web Search Brochure New Yorker US Airways Attache Other, please specify below

If other, please specify:

How did you hear about this program?*
-Select One- Word of Mouth Web Search Brochure Dartmouth Valley News Other, please specify below

If other, please specify:

Please provide details on your experience with Spanish (course work and/or life experience):*

Language self-evaluation:*
-Select One- Non/very limited Can communicate basic information Can express myself in short phrases Can converse and express myself in sentences

Rassias Center Language Program

Language * Select One... French German Italian Spanish

Payment

Payment is required before you submit this form. You can submit your payment here.

Please contact us if you have any questions about the registration process.