Partners in Cross-Cultural Learning - Community Partner Information Form

Personal Information

First Name:

Last Name:

Gender:
  

Age Range:

Marital Status:

Other household members? Please list age and gender of each:

Do you have pets? If yes, please state the number and type of animal:

Does anyone in your household smoke?

Contact Information

Home Address:

City:

State/Province:

Zip/Postal Code:

Home Phone Number with area code:

Alternative Phone Number with area code:

Best time to reach you:
Morning
Afternoon
Evening

Email Address (that you check regularly):

International Experience

What is the extent of your international experience? (Examples: travel, student host, work abroad, etc.)

What languages do you speak (besides English)?

Professional and Recreational Interests

What is your occupation?

What hobbies or activities do you enjoy?

Please list any memberships or affiliations you have (e.g. Kiwanis, P.T.A., professional organizations, etc.)

What do you hope to gain from your PICL experience?

Preferred Student Partner Attributes

Gender:

Region/Country of Origin:

Choice 1:  

Choice 2:  
No Preference

Age:

Language Ability:

Do you object being paired with a student who smokes?
Yes
No
No Preference

Please list any additional partner attributes that might be important to you: (religion, smoking, marital status, etc.)

If we cannot meet all of your preferences, will you accept being paired with another student?

Are you interested in being paired with more than one student at this time?

Would you be able to occasionally house a student overnight in your home?

If yes, how many?

 Please click the "Send Information" button below to submit your information when you are ready.

 Thank you for applying! We will contact you soon.

Questions, Comments, Suggestions?

If you have any questions about the Partners in Cross-Cultural Learning Program at SUNY-Plattsburgh, please contact the PICL Coordinator:

Carolina Dela Rosa
Global Education Office

State University of New York at Plattsburgh
Kehoe Administration Building, Room 210
101 Broad Street
Plattsburgh, New York 12901 USA

Phone: (518) 564-3287
Fax: (518) 564-3292
Email: picl@plattsburgh.edu