All levels and abilities are welcome   

APPLICATION FORM - ART MAKING IN HABANA
Program Dates
CIRCLE� ONE PLEASE
January���� 4-11 February 15-22
January� 11-18 May������� 17-24

Name (print as in your passport):

Mailing Address:

Home Physical Address (for UPS, FedEx mailings):

Birth Place:

 Birth Date:

Passport #:

 Passport Expiration Date:

Citizenship:

 Occupation:
Home Phone: Work Phone:
E-mail: Fax:

Mother�s Maiden Last Name:

Accommodations:
Double ____���Rooming with:
Single� ____

Check selected exit airport:    NY ____���� Toronto ____����� Miami ____���� Nassau ____

                                            For other exit point, please contact us.

Were you born in Cuba?�     ��YES _____ NO _____

If yes, please contact us immediately.

In case of emergency, please contact:
Phone:

How did you hear about CubArtEdu?
 
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