General Information

    Participant desires to take part in the following program at CEHS. All program participants must be at least 18 years of age.

    "*" indicates required fields

    If No, write emergency address here:

    Your date of birth*

    Social Security Number*
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    High School/College/University you are now attending:

    Do you have a medical condition or illness? If so, please explain. This information is confidential.

    Applicant’s signature / name:

    Date:

    By including my name and date I hereby certify that all the information I have provided on this application form are correct.

    In accordance with the established Organic Law 15/1999 for the Protection of Personal Data, the information collected in this document is included in an automated processing file belonging to Richard Crescenzo D’Augusta (Tax I.D. # X2676498B), trade name (CEHS), in compliance with the security measures required by law, for the purposes that are clear from this document; the user reserves the right to access, rectification, erasure or objection by means of a written petition, together with a copy of a valid I.D. card, to the following address: C/San Valentín, 12, Entresuelo A, 40003, Segovia, España.