Registration

Registration on line

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Family Name

First Name

Sex	Date of Birth

Home Address

Town

Zip Code

Country

Other

Phone

Fax

E-mail

Profession

Mother Tongue

Other Languages

I hereby register for the following course:

Starting date

Number of weeks

Accommodation

Kitchen

with private bathroom

How many stars?

in a room with

bed/s

room/s

I would like to share the room with

Competence of the Italian language

How long have you studied?

Where

Name of the School/Teacher/University

How did you first hear about the school Cultura Italiana?

Which one?

Do you need a baby-sitter?

Do you smoke?

Do you have any allergies?

1. Do you have any specific interests for the program of after-class activities?
2. Do you have special request?

In order to validate the registration a deposit of Euro 130 is required

I would like to pay by

Visa, Mastercard

In this case your enrollment will remain pending until the receipt of your deposit

I read and accept the school procedures


I agree to receive from Cultura Italiana information about their courses and initiatives and authorize the use of my data only for these purposes