Partners in Cross-Cultural Learning - Student Partner Information Form

Personal Information

First/Given Name:

Last/Family Name:

SUNY Plattsburgh BannerID:

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 

Is this your first time living in the United States?

Yes 
No 

Please list your first semester+year of enrollment at SUNY Plattsburgh?

Please list your anticipated final semester+year of enrollment at SUNY Plattsburgh?

Are you allergic to any animals?

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:

Cell phone number with area code:

Best time to reach you:

Morning
Afternoon
Evening

Plattsburgh Email address:

Professional and Recreational Interests

What do you want to study at SUNY Plattsburgh?

What hobbies or activities do you enjoy?

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

May we share the information you provided on this form with your American friend?

Yes 
No

Partnership Requests (your ideal characteristics for your new American friend)

Gender:

Male 
Female
No Preference

Age:

Younger adult(s) 
Older Adult(s) 
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