Partners in Cross-Cultural Learning - Application Form for Students

Personal Information

First/Given Name:

Last/Family Name:

Date of birth (MM/DD/YY):

Age:

Home Country:

Religion (optional):

Native Language:

Other Language (s) spoken:

Fluency in spoken English:

Excellent 
Good 
Fair 
Poor

Gender:

Male 
Female

Marital Status:

Single 
Married 
Other 

Will you be staying on campus during vacation periods?

Yes 
No 

For how many semesters do you intend to be enrolled in SUNY Plattsburgh?

Do you dislike animals/pets, or are you afraid of or allergic to them?

Yes 
No 

Do you smoke?

Yes 
No 

If you have any allergies or dietary requirements, please list them:

If you have any medical conditions that your partner should know about, please list them:

Local Contact Information

Local/Campus Mailing Address:

City:

State/Province:

Zip/Postal Code:

Plattsburgh Phone Number:

Cell Phone Number with area code:

Best time to reach you:

Morning
Afternoon
Evening

Email Address (that you check daily):

International Experience

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

Professional and Recreational Interests

 What is/was your job in your country?

What is your major at SUNY Plattsburgh?

What are your professional goals?

What hobbies or activities do you enjoy?

Why do you want to be paired with an American PICL partner?

Partnership Requests

Gender/Marital Status:

Single Male 
Single Female
Married couple 
No Preference

Age:

Younger adults 
Older Adults 
No Preference

Smoking:

Smoker (s) 
Non-Smoker (s) 
No Preference

Children:

Family with no children 
Family with children
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 partner?

Yes 
No

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