Humboldt State University

Language and Culture Program in Oaxaca, Mexico

A P P L I C A T I O N

All blanks must be completed. Answer in detail where applicable. Informaton provided in this application is held in confidentiality.

Today's Date:

I. STUDENT INFORMATION:

Name:		Gender:	Gender Male Female
Student ID #		Date of Birth:	Month 01 02 03 04 05 06 07 08 09 10 11 12 / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 < 1930

Your current address:
Street:
City:	State: Zip:
Telephone:
Current Email:

Do you have a passport? No Yes If "Yes", from what country?

Name and Address of Parent, Guardian or Relative:
Name:
Relationship:
Your parent's or guardian's address:
Street:
City:	State: Zip:
Telephone:
Current Email:

II. ACADEMIC INFORMATION

Major:	Advisor/s:
Minor:	Grade Point Average:

What is your present student status? HSU student CR student CSU student High school student Comm Ed student Other Not currently enrolled If you are currently a student at a school other than HSU or CR, write school name:

What is your class standing? Freshman Sophomore Junior Senior Graduate Other If "Other", explain:

Are you a native speaker of Spanish? No Yes

What is your college Spanish language level? Spanish Level 1 semester 2 semesters 3 semesters 4 semesters 5 semesters or more Graduate Other

Are you currently taking Spanish classes? No Yes If "Yes", list classes you are currently taking:

List the Spanish courses you have taken:

Do you have any special academic circumstance or academic experience you feel should be communicated? No Yes
If "Yes", explain:

How will your participation in the Oaxaca Program be financed? Self-funded Parents Relatives Not Parents Financial Aid Other If "Other", explain. If "Financial Aid", list specific type of financial aid sources.

III. STUDENT HEALTH INFORMATION
Have you been or lived abroad? No Yes If "Yes" where and for how long?
Are you covered by a Health Insurance* with repatriation coverage? No Yes If "Yes", who is the carrier and what is the policy number?	Carrier: Policy #:
*Note: If not insured, you will be required to buy a standard International Student Health/Accident Insurance.

Do you have any medical situation that may have an impact during your stay abroad? No Yes
If "Yes", explain:

Do you have any allergies? (to animals, food, environment, other) No Yes If "Yes", explain:

IV. STUDENT INPUT FOR FAMILY SELECTION

Mark the family group with whom you would like to live:

Traditional nuclear family with kids Traditional nuclear family with teenagers Traditional nuclear family with college students Traditional nuclear family with adults only Traditional nuclear family with any combination of the above I am open to try any family group

If none of the above mentioned family groups are accomodating to you, please explain as clearly as possible your living preferences
Note: Under special circumstances you may request independent living accomodations. Please explain clearly why you cannot live with a family and describe your minimal essential living conditions.

Do you smoke? No Yes

Do you mind if your host family smokes? No Yes

Are you a vegetarian? No Yes If "Yes", identify your tolerance level

Do you mind if your family is not vegetarian? No Yes

Do you have any dietary restrictions? No Yes If "Yes", explain

Is there any personal circumstance that should be communicated to the host family in order to prevent later conflicts? For example: sleepwalking, night person, early riser, loud snoring, special fears or phobias, etc. No Yes
If "Yes", explain

How would you like to be treated by your host family? For example: as a family member and someone who is integrated in family activities, or as an independent person with a certain distance between you and family activities, etc. Explain your preference:

Describe yourself. Provide your character and life attitude that may be useful and pertinent when selecting your host family:

Personal hobbies and interests:

By submitting this application I state my serious intent to participate in the Oaxaca, Mexico Study Abroad Program. In addition, if accepted in the Oaxaca program, I will abide by all regulations of the California State University and Colleges in general and the Humboldt State University in particular related to student conduct. Also, I will abide by all regulations of the host institution related to student conduct. The information provided in this application is truthful and accurate to the best of my knowledge.

Enter your name:

If accepted you will need to complete all legally required forms for HSU Studies Abroad Programs and hold a valid passport.

If you are not an HSU student, please send a copy of your unofficial transcripts to: Oaxaca Program Director Dept. World Languages & Cultures Humboldt State University 1 Harpst Street Arcata, CA 95521