Application Form Exchange Program PUCV, Chile

Page 1/6

APPLICATION FORM SEMESTER/FULL YEAR PROGRAM

I. PERSONAL INFORMATION

Name Passport number Citizenship Gender Female Male

Last name Birth date

(month/day/year)

Mother tongue

Address Postal Code State Phone 1 Cell # e-mail 1 City Country Phone 2 Fax e-mail 2

Person to contact in case of emergency Relationship with student

Phone

e-mail

Application Form Exchange Program PUCV, Chile

Page 2/6

II. ACADEMIC INFORMATION

Home University Major Minor

Courses you intend to do while at the PUCV (go to www.ucv.cl, click on Facultades y Carreras, and search on each school)

1. Have you ever studied Spanish? Yes No 2. What is your proficiency in Spanish? Very good Good Fair Poor None How many semesters?

3. What semester do you wish to attend at the PUCV? Semester one (March-July) 4. How many semesters do you plan to stay at PUCV? one two Semester two (August-December)

Application Form Exchange Program PUCV, Chile

Page 3/6

III. ACCOMMODATION INFORMATION

What kind of accommodation would you prefer during your stay in Chile? Home-stay Independent

If you choose Home-stay (living with a family - single room), please go ahead with the following section. Please keep in mind that this is a semester-based arrangement. Home-stay fee is USD3,050, and it must be paid entirely upon arrival at the Accounting office of the PUCV and is valid for the official dates of each term. Extra days must be paid directly by the student to the family at the daily fee of $9500 (Chilean pesos). If you choose Independent, our staff will provide you a list of useful addresses so you can find a place that matches your preferences and budget, by yourself. You (not the PUCV) will remain fully responsible for any decisions made in this concern . (HOME-STAY) 1. Do you have any allergies, medical conditions or dietary needs? _____________________________________________________________________________ _____________________________________________________________________________ 2. Do you smoke? Yes 3. Do you mind living with people who smoke? Yes No No

4. Regarding pets, what do you prefer? in-door out-door

(HOME-STAY) no pets at all

5. What sort of family would you like to live with? (check one) Family with children Family with children of university-age Family with no children Young couple with no children Divorced/widow woman with children Divorced/widow man with children Single/divorced woman Single/divorced man

Application Form Exchange Program PUCV, Chile

Page 4/6

6. Youd like your host family to: Speak English not to speak much English not to speak English at all

7. What role would you like to play within your family? Very independent: you dont mind if your family is out most of the day. Only few familiar activities. Lot of time and room for yourself. A bit interactive: youd like to participate as a part of the family but, at the same time, keep your independence. You want the family to invite you to their activities but not feeling forced to participate all the time Very interactive: youd like to become a part of your host family and to be considered as another child: having dinner together every night and participating of all the familys activities 8. What characteristics do you consider most important in a family? _____________________________________________________________________________ _____________________________________________________________________________

9. Please use the next lines to describe yourself providing as many details as you can. Tell us about your personal characteristics, likes and dislikes, favorite sports, hobbies, etc. Provide us with any information you consider important to make your stay in Valparaiso an enjoyable experience. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Application Form Exchange Program PUCV, Chile

Page 5/6

IV. MEDICAL INFORMATION

1. Do you have any medical pre-existing condition? Yes No

2. Do you currently receive any treatments or medication on a regular basis? Yes No

3. If the answer 2. is positive, please indicate what medicine are you prescripted: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. Do you have any physical limitations or disabilities? Yes (Name it________________________________) No

5. Have you ever had a major illness? Yes (Name it_________________________________) No

6. Have you ever had a major surgical operation or been advised to have one? Yes (Name it_________________________________) No

7. Have you ever been hospitalized? Yes No

8. Have you ever received treatment for drug or alcohol addiction? Yes No

9. Have you ever been treated by a psychiatrist or psychologist for any mental, emotional or nervous disorder? Yes 10. Have you ever had treatment in a mental institution? Yes No No

Application Form Exchange Program PUCV, Chile

Page 6/6

V. OTHER INFORMATION
1. How did you find out about the International Program of PUCV? Magazine Travel Guide Friends Internet 2. Why did you choose Chile and specifically the PUCV to study abroad? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Study Abroad Office Past participants Other (Name it________________)

VI. DECLARATION
By signing below, I certify that the above information is true to the best of my knowledge. I also acknowledge the following: I, and my parents or guardians, agree to release the PUCV and its staff from any claims arising out of the provision of medical care in my host country.

Students signature

Date (month/day/year)

Applications have to include the following documents in order to be considered:

Complete application form Letter or certificate, properly signed, of International Medical Insurance that covers 100% of any medical expenses arising from illness and/or accident during all stay in Chile (in English or Spanish). It must clearly mention the name of the applicant and the period of coverage. Copy of transcripts Copy of passport Recommendation letter from a Professor of home university (in English or Spanish) Approval for studying abroad issued by the home university (in English or Spanish) Motivation letter written by the student telling why she/he wants to join PUCV USD$80,00.- application fee (check to Pontificia Universidad Catlica de Valparaso). Applicants from partner universities (with academic cooperation agreement with PUCV) are released from this payment.