Personal Information and Questionnaire Form
Friends Across Borders
Vilches - Curepto, Chile Program February 10 - 26, 2016
As a participant of Friends Across Borders (FAB) of the Maryknoll Lay Missioners (MKLM) we request
that you fill out this five-page form and give it to the manager at the orientation session in October
or November. Your answers will help us to know you and your expectations and needs. Please have
this form ready at the orientation session with the waiver form and a copy of your passport.
Part One – Basic Emergency and Contact Information
Name:
Passport #:
Citizenship:
Date of Birth:
Age:
University:
Major:
Sex:
T-Shirt Size:
Year Grad:
Home Address:
City:
Home Phone:
State:
(
)
Cell Phone:
Zip Code:
(
)
E-mail address:
Facebook:
Skype:
We request the information of your parents in case of any emergency and also to provide any other
needed information before, during, and after the program.
Father Name:
Phone:
(
)
Phone:
(
)
Father E-mail address:
Mother Name:
Mother E-mail address:
 P.O. Box 307  Maryknoll, NY 10545-0307  914-236-3474
 [email protected] www.friendsacrossborders.org
In case of emergency Maryknoll Lay Missioners will contact first the Office of International Studies. In
the event of needing immediate contact with your family please let us know who we should contact
first (provide emergency information only if different from your parents).
Mother:
Father:
Emergency Contact Name:
Emergency Phone: (
)
Other:
Relationship:
Emergency E-mail:
MKLM Guidelines: While all of our immersion trips are planned in order to provide a safe and
meaningful experience for you, we would like to remind you that you will be in settings very different
from those found in the United States. So, we ask that you remain flexible, willing to adapt to a
simple lifestyle, ready to follow the safety guidelines provided, and open to experiencing and
learning about another culture. Please initial here __________ to indicate that you will follow FABMKLM guidelines.
Part Two – Personal Information and Preparation
Please let us know why you are participating in this program:
1. What previous experiences may have prepared you for this experience? (Live in or visit to another
country, cross cultural experience, etc.)
2. How could this experience help you in your life and study abroad?
3. Do you have any special dietary requirements? Yes
No
. If yes, please
Indicate:
4. Medical concerns: Our immersion experiences to overseas countries take us to dusty and
sometimes windy environment. Please indicate below if you suffer from airborne allergies or asthma.
Also, indicate below any other medical conditions you think we should know about and perhaps
plan around:
Airborne allergies, asthma: Yes :
No:
Other physical conditions:
5. Other questions or comments: If you have questions or concerns in any of the above items please
let me know:
 P.O. Box 307  Maryknoll, NY 10545-0307  914-236-3474
 [email protected] www.friendsacrossborders.org
Part Three – Spanish Classes and Proficiency Information
1. Please let us know what level of Spanish classes you have taken at the University and how
prepared you feel (indicate number of classes and if you had Spanish in High School or earlier):
2. Level of proficiency in Spanish:
Beginner
Conversational
Fluent
Interpreter
3. Please mark any specific area you need improvements:
Grammar Review
Increase Vocabulary
Conversation
Writing Papers
4. How confident are you with your Spanish?
Part Four – Information about lodging
This program offers an alternative experience to life in Chile, apart for the large urban setting of
Santiago.
 You will live with middle-lower working class families in the rural town of Curepto (10,812
inhabitants). Curepto is a town and commune in the Chilean Province of Talca, located in the
Maule Region. Maryknoll has worked in that area since 1945.
 It is important to note that urban and rural conditions are different from the US reality you
may know. Animals and pets are present in the homes.
 These families are familiar with the US culture, because of the Maryknoll presence in the area
and they have hosted students in the past.
 You may find yourself out of your comfort zone for a week to 10 days, but you will experience
love, care, and respect by the people you will live with and encounter. There are probabilities
of sharing a bedroom with another student or a child of the family.
 You will experience and learn about a reality, history, culture, and lifestyle different from the
one you will experience during your semester of studies in Santiago.
 In order to understand the Chilean idiosyncrasy, history, and wider reality it is important to
know the roots of the Chilean culture; and they are in the rural areas of Chile.
Following are several questions that will help us make the best family placement possible for you.
We don’t promise to accommodate all your needs but we want to take them into consideration
when we do the placement with your family.
 P.O. Box 307  Maryknoll, NY 10545-0307  914-236-3474
 [email protected] www.friendsacrossborders.org
1. Knowing that few houses won’t have a separate bedroom, are you willing to share a room with
someone?
2. Regarding the make-up of the households: Several families are composed of just adults, for
families with several children is difficult to have students, but there are few families that have
small children and/or young people. Please mark your preference.
Family w/small
Family w/ children &
Family only with youth
Only Adults
children
youth
3. In poor areas of Chile you will find many stray dogs and cats. In the City of Curepto, where you
will live, the families will have several pets. Please mark the animal you will have problems being
around to:
CATS
DOGS
BIRDS
OTHERS
4. Chile doesn’t have lethal poisonous bugs, but insects are very present especially during summer
months. Some people could have allergic reactions to insects present. Are you allergic to any
kind of insect or bee? Please write them down.
5. Chile is a smoking country and we can’t change that reality but we can help in advising the
family members regarding your preferences. Please mark one.
I do not mind a person
smoking
only if the persons smokes in
designated areas of the house
I have difficulties with
people smoking
Part Five – Regarding Activities, Taste, Likes and Health
Please respond the following questions:
1. Is there any food you are allergic to?
2. Is there any food you don’t like?
3. We will have several activities that will start very early in the morning or will end late at
night. We would like to know about your sleep habits to understand your needs. Please
mark what apply to you.
No problem w/
Early raiser
Late raiser
Night person
schedule
 P.O. Box 307  Maryknoll, NY 10545-0307  914-236-3474
 [email protected] www.friendsacrossborders.org
4. This program has many activities such as swimming in the river, singing, dancing, and
several other outdoor activities. Are there activities you enjoy doing and those you prefer not
to do. Please write them down:
Activities
I Enjoy
I Don’t Like Health Issue
5. Chile is a Catholic country and the overall environment and families are Catholic. We
consider this reality a cultural aspect of the experience as well as spiritual. The reception
and welcome will be in the Parish at a Mass. However, in order to be sensitive to each
participant we would like to know about your openness to participating in religious
celebrations:
I am Catholic
I’m not Catholic but I don’t mind
participating in Catholic activities
I have difficulties participating
in a practice that’s not mine
6. Questions and comments: If you have questions or concerns please let me know. Feel free
e-mailing me if necessary. I look forward to seeing you in October or November at the
orientation session:
Please initial here _____ that you have provided all needed information.
Please hand this form with a signed waiver form and a copy of your passport at the orientation
session. Thank you very much for your responses!
Your signature:
Date:
 P.O. Box 307  Maryknoll, NY 10545-0307  914-236-3474
 [email protected] www.friendsacrossborders.org