Travel Ambassador Application

Name(s) __________________________   ______________________________

Address _________________________________________  City_________________  Zip ____________

Phones ( Land)__________________  (Cell)________________   Email ___________________________

Age(s) _______________   Gender(s) ________________   Marital Status _________________________

Occupation(s) _____________________________________            Retired?  _______________________

Spanish Language Ability  _______none/poor  _______beginner  _______intermediate  ________fluent

How important is it for you to be matched with a Costa Rican host who speaks some English?

______Very  _____Somewhat  ______Not an issue, we can use dictionaries and sign language if needed!

Do you smoke?  ______   Do you enjoy an alcoholic beverage?  ____daily _____ on occasion _____never

Are you allergic to certain foods or do you require any special diet?  _____________________________

What foods do you prefer / dislike?  _______________________________________________________

Do you have ANY allergies?  ______________________________________________________________

Hobbies/Interests ______________________________________________________________________

_____________________________________________________________________________________

Do you have any preferred bed or sleep accommodations? (extra pillows, etc.) _____________________

How would you describe your activity level?  _____sedentary  _____good, but tire easily  _____fit/active

Are you able to climb 1) steep stairwells, 2)steps onto buses, 3) paved / unpaved hiking paths? _____________________________________________________________________________________

Do you have physical disability limitations? __________________________________________________

Do you have any known medical issues or take any special medications?  ________________________________________________________________________________________________________________________________________________

 Before departing, provide your health insurance policy info or, if none, provide purchased traveler insurance info:

carrier name __________________________ policy #_______________  valid dates______________

traveler ins. carrier _____________________ policy #________________ valid dates__________

Emergency Contact Information: 

name_________________________ 

phone number_______________

email________________________  address________________________ 

relationship to me______________________________________

Recent photo(s) attached? (small digital preferred) _________________

Attach check(s) payable to Oregon-Costa Rica Partners of the Americas. We ask that if you plan to travel in 2020 that you join our organization as soon as possible in 2019. Please total your dues and deposit and mail to the following address:

Oregon-Costa Rica Partners of the Americas

3220 Forest Gale Dr. Forest Grove, OR 97116

2019 Dues ($25) ________     2020 Dues ($25)  ________ 

+ Nonrefundable Deposit ($50)  ________

Total ______________

What do you think makes a good house guest? ______________________________________________

Why do you want to travel to Costa Rica as a homestay guest?  _________________________________