High School Abroad

Fields marked in red are required. First Name: Last Name: Company Name: Title: Address 1: Address 2: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Non-US/Canada Zip: Country: United States Canada Other Phone:   Use Format: xxx-xxx-xxxx Alternate Phone:   Use Format: xxx-xxx-xxxx Cell Phone:   Use Format: xxx-xxx-xxxx Email: Fax:   Use Format: xxx-xxx-xxxx Company Website:   http://

Additional information about you

I am a:   Student Parent   School Counselor Teacher   Independent Counselor

Counselor/Teacher E-Mail address:

Primary additional language I've studied:   Spanish French Latin Mandarin Japanese German Italian Portuguese

If you speak or study more than one additional language or one that isn't on the list above, please add it here:

My current year in school:   8 9 10 11 12   12+              Month I will graduate:     Year I will graduate:

Tell us about your school

Name of my high school:

My Guidance Counselor's name:

I'm interested in High School Abroad . . .

(I'm in High School now.)

I'd like to travel to: (I can change my mind later.)   --- Please Select --- Australia Brazil Chile China Costa Rica France Germany Ireland Japan Italy Spain

I'd like to go for:   Semester Academic Year   Summer

I'd like to start:   Jan/Feb 2010 Summer 2010   Aug/Sept 2010 Jan/Feb 2011   Summer 2011 Aug/Sept 2011   Jan/Feb 2012 Aug/Sep 2012

I am interested in Gap Year Abroad . . .

(I will have graduated before I go abroad.)

I'd like to travel to: (This is my first choice.)   --- Please Select --- Valparaiso, Chile Shanghai, China Santiago, Dominican Republic Paris, France Tokyo, Japan Seville, Spain

I'd like to go for: (Semesters range from 2.5 to 4 months, Academic Years range from 8 to 10 months.)   Semester Academic Year

I'd like to start:   Jan/Feb 2010 Aug/Sept 2010   Jan/Feb 2011 Aug/Sept 2011   Jan/Feb 2012 Aug/Sep 2012

How did you hear about CIEE?

How did you hear about us?   Parent / Friend Exchange Student   School Counselor / Teacher Other   CIEE visited my school Google   Yahoo Facebook   Email from CIEE        If Other, please specify:

Questions or comments?

Additional comments: