Custom Program Request Form

General Information

Name:
Language I teach:
I heard about ISE from:

Contact Information

School Name
School Address
School Phone
School Email
Alternate Email
Alternate Phone

Home Cell

Program Information

Destination Country
Preferred Departure & Return Dates
U.S. Departure City
Foreign Arrival City
Foreign Departure City
Program Length (days)
Estimate # of Students
Estimate # of Leaders
Desired Program Price Range
Please include leaders’ cost in the student price

Yes No

Program Description - Family Stay

I would like an ISE-arranged Family Stay for days
I will arrange our own Family Stay in for days
I do not want to include a family stay

During the Family Stay, leaders would like to:

Stay in a hotel in

double room(s) single room(s)
Stay with host families
Make private arrangements

Program Description – Travel Portion

We would like ISE to book hotel accommodations for nights (students in doubles, triples, quads)
Leader accommodations in

double room(s) single room(s)
We prefer to travel by:

Proposed Itinerary (list cities/towns in order you wish to visit them)

Day	City/town	Transportation	Excursions and/or Meals
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Program Description - Meals & Excursions

# of lunches pre-arranged and pre-paid by ISE
# of dinners pre-arranged and pre-paid by ISE

ISE-arranged excursions and/or activities

Allowances and Leader Stipends

Entrance Fee/Allowance per student
Meal Allowance per student
Meal Allowance per leader
Leader Stipend per student

Other Allowances - if applicable

$ for
$ for

Other Comments/Wishes