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 Gender Female Male This info is necessary for housing assignments. For other genders please contact AIA.Date of Birth MM slash DD slash YYYY Passport InformationName 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 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 Relationship Home PhoneWork PhoneCell PhoneEmail Contact TwoName First Last Relationship Home PhoneWork PhoneCell PhoneEmail Medical InformationVOLUNTARY - for Emergencies only. Medical info will not impact eligibility for enrollment.Personal Doctor's Name Doctor's Office PhoneInsurance Company Policy Number Study Abroad Health Insurance Program Yes No Additional 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 School University I have never taken Italian I 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.
