Student Information Form Please complete all fields. If a field does not apply to you enter ‘NA”. General InformationName First Last Permanent Street Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail GenderFemaleMaleThis info is necessary for housing assignments. For other genders please contact AIA.Date of Birth Date Format: MM slash DD slash YYYY Passport InformationName as it appears on passport (i.e. including middle names)CitizenshipPassport NumberPlace of Issue (city, country)Place of Birth (city, state and country)Date of IssueDate of ExpirationT-Shirt SizePlease SelectWomen's SmallWomen's MediumWomen's LargeWomen's X-LargeMen's SmallMen's MediumMen's LargeMen's X-LargeEmergency Contact InformationPlease supply two people whom we should contact in the event of an emergency.Contact OneName First Last RelationshipHome PhoneWork PhoneCell PhoneEmail Contact TwoName First Last RelationshipHome PhoneWork PhoneCell PhoneEmail Medical InformationVOLUNTARY - for Emergencies only. Medical info will not impact eligibility for enrollment.Personal Doctor's NameDoctor's Office PhoneInsurance CompanyPolicy NumberStudy Abroad Health Insurance ProgramYesNoAdditional Medical Information - VoluntaryYou may add any physical or mental health info you think is relevant - consider what would help us accommodate special needs (i.e. food allergies, veganism, vegetarianism etc., difficulty walking, etc.) this space is provided for confidential, voluntary information and will not impact enrollment - you may also offer additional info after arrival.Additional Personal InformationYou 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 ExperienceWe would like to know about your experience with Italian.I have taken Italian language courses in (choose one):High SchoolUniversityI have never taken ItalianI took Italian courses for:I would describe my Italian language skills as:Graphic ExpressionCOMPLETE 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: Sketching / Freehand Drawing Painting Writing Video / Film Drafting (digital) Modeling (digital) Collage Photography Drafting (manual) Modeling (physical) Other (list below)I hope to develop the following skills while I am abroad.