Student Information Form

General Information

Please indicate which Cal Poly Program you are participating in.*

Architecture
Software Engineering
Mechanical Engineering

Name

First Middle Last

Permanent Street Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email

Gender

Female
Male

This info is necessary for housing assignments. For other genders please contact AIA.

Date of Birth

Passport Information

Name as it appears on passport (i.e. including middle names)

Citizenship

Passport Number

Place of Issue (city, country)

Place of Birth (city, state and country)

Date of Issue

Date of Expiration

T-Shirt Size

Emergency Contact Information

Please supply two people whom we should contact in the event of an emergency.

Contact One

Name

First Last

Relationship

Home Phone

Work Phone

Cell Phone

Email

Contact Two

Name

First Last

Relationship

Home Phone

Work Phone

Cell Phone

Email

Medical Information

VOLUNTARY - for Emergencies only. Medical info will not impact eligibility for enrollment.

Personal Doctor's Name

Doctor's Office Phone

Insurance Company

Policy Number

Study Abroad Health Insurance Program

Yes
No

Additional Medical Information - Voluntary

You may add any physical or mental health info you think is relevant - consider what would help us accommodate special needs (i.e. difficulty walking, etc.) this space is provided for confidential, voluntary information and will not impact enrollment - you may also offer additional info after arrival.

Please let us know if you have a food allergies (i.e. nut allergy, seafood allergy, etc.) or have dietary preferences (i.e. vegan, vegetarian, pescatarian, kosher or halal, etc.) This information is very important as we will book group dinners and inform restaurants of your preference in advance. If you do not provide this information, accommodations cannot be guaranteed.

Additional Personal Information

You may add any additional comments here this space is provided for voluntary information and will not impact enrollment - you may also offer additional info after arrival.

Language Experience

We would like to know about your experience with Italian.

I have taken Italian language courses in (choose one):

High School
University
I have never taken Italian

I took Italian courses for:

I would describe my Italian language skills as:

Graphic Expression (Architecture only)

COMPLETE IF APPLICABLE TO YOUR STUDY PROGRAM

We would like to know about your talents and ambition.

I feel I have a particular talent/skill in the following media:

Other (list below)

I hope to develop the following skills while I am abroad.