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Application Form – Exchange Program – PUCV, Chile

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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

What is your proficiency in Spanish? Very good Good Fair Poor None How many semesters? 3. and search on each school) 1. How many semesters do you plan to stay at PUCV? one two Semester two (August-December) .ucv. click on “Facultades y Carreras”. Have you ever studied Spanish? Yes No 2. Chile Page 2/6 II.cl.Application Form – Exchange Program – PUCV. What semester do you wish to attend at the PUCV? Semester one (March-July) 4. ACADEMIC INFORMATION Home University Major Minor Courses you intend to do while at the PUCV (go to www.

Do you have any allergies. If you choose “Independent”. medical conditions or dietary needs? _____________________________________________________________________________ _____________________________________________________________________________ 2. by yourself. Extra days must be paid directly by the student to the family at the daily fee of $9500 (Chilean pesos). Do you mind living with people who smoke? Yes No No 4. our staff will provide you a list of useful addresses so you can find a place that matches your preferences and budget.Application Form – Exchange Program – PUCV. Regarding pets. Home-stay fee is USD3. 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 . Chile Page 3/6 III.050. what do you prefer? in-door out-door (HOME-STAY) no pets at all 5. Do you smoke? Yes 3. please go ahead with the following section. 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. Please keep in mind that this is a semester-based arrangement. You (not the PUCV) will remain fully responsible for any decisions made in this concern . (HOME-STAY) 1.single room). 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 .

Provide us with any information you consider important to make your stay in Valparaiso an enjoyable experience.Application Form – Exchange Program – PUCV. at the same time. Tell us about your personal characteristics. Chile Page 4/6 6. likes and dislikes. favorite sports. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ . keep your independence. What role would you like to play within your family? Very independent: you don’t mind if your family is out most of the day. etc. A bit interactive: you’d like to participate as a part of the family but. Only few familiar activities. You want the family to invite you to their activities but not feeling forced to participate all the time Very interactive: you’d 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 family’s activities 8. Lot of time and room for yourself. hobbies. You’d like your host family to: Speak English not to speak much English not to speak English at all 7. 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.

If the answer 2. Have you ever had treatment in a mental institution? Yes No No . Do you currently receive any treatments or medication on a regular basis? Yes No 3. Do you have any physical limitations or disabilities? Yes (Name it________________________________) No 5. is positive. emotional or nervous disorder? Yes 10. Have you ever received treatment for drug or alcohol addiction? Yes No 9. Have you ever been hospitalized? Yes No 8. Chile Page 5/6 IV. Do you have any medical pre-existing condition? Yes No 2. MEDICAL INFORMATION 1. Have you ever been treated by a psychiatrist or psychologist for any mental. Have you ever had a major surgical operation or been advised to have one? Yes (Name it_________________________________) No 7. Have you ever had a major illness? Yes (Name it_________________________________) No 6. please indicate what medicine are you prescripted: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4.Application Form – Exchange Program – PUCV.

OTHER INFORMATION 1. properly signed. Student’s signature Date (month/day/year) Applications have to include the following documents in order to be considered: Complete application form Letter or certificate. Chile Page 6/6 V. .00.. agree to release the PUCV and its staff from any claims arising out of the provision of medical care in my host country. How did you find out about the International Program of PUCV? Magazine Travel Guide Friends Internet 2. It must clearly mention the name of the applicant and the period of coverage. 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). I certify that the above information is true to the best of my knowledge. I also acknowledge the following: I. Why did you choose Chile and specifically the PUCV to study abroad? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Study Abroad Office Past participants Other (Name it________________) VI. Applicants from partner universities (with academic cooperation agreement with PUCV) are released from this payment. and my parents or guardians. 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.Application Form – Exchange Program – PUCV. DECLARATION By signing below.application fee (check to “Pontificia Universidad Católica de Valparaíso”).