Pontifícia Universidade Católica do Rio Grande do Sul
INTERNATIONAL AFFAIRS OFFICE
SCHOOL OF LETTERS
PUCRS-HARVARD PORTUGUESE AND COMMUNITY SERVICE PROGRAM 2013
This program will take place from January 7 to January 18 of 2013. The
deadline for submitting this application is October 15, 2012. Students will
be informed if they have been selected to participate in this program by
Place your
photo here
October 31, 2012. For more information, access:
http://www3.pucrs.br/portal/page/portal/pucrs/Capa/AdministracaoSuperior/aa
ii/aaiiEnglishSite/aaiiPUCRSHarvard
PERSONAL INFORMATION
Family name______________________________________________________________________________________________
Given name_______________________________________________________________________________________________
Gender: Male 
Female 
Contact address__________________________________________________________________________________________
_____________________________________________________________________________________________________________
Telephone number_______________________________________________________________________________________
Email address_____________________________________________________________________________________________
Skype name_______________________________________________________________________________________________
Date of birth___________________________________Nationality_______________________________________________
Passport number________________________________Native language_______________________________________
ACADEMIC INFORMATION
Please give details about your educational background, including current study and major:
Studying for: BA 
MA 
PHD
What is your major?______________________________________________________________________________________
What is your minor (if any)?____________________________________________________________________________
PORTUGUESE LANGUAGE EXPERIENCE
Please give details about your experience with the Portuguese language.
Studied university-level Portuguese for: 0 semesters 
1 semester (check here if
currently enrolled in your first Portuguese language class) 
more than 1 semester 
If your prior experience with Portuguese has not been in a university setting, please
explain.____________________________________________________________________________________________________
Campus Central
Av. Ipiranga, 6681 – prédio 1 – sala 110 – CEP 90619-900
Porto Alegre – RS - Brasil
Fone: (51) 3320-3660 – Fax (51) 3320 – 3885
E-mail: [email protected]
www.pucrs.br
Pontifícia Universidade Católica do Rio Grande do Sul
INTERNATIONAL AFFAIRS OFFICE
SCHOOL OF LETTERS
HOMESTAY INFORMATION
Have you had a previous homestay experience? Yes 
No 
If so, where?______________________________________For how long?________________________________________
What hobbies do you enjoy?_____________________________________________________________________________
Do you smoke? Yes 
No 
Do you have any allergies? Yes 
No 
If so, what are they?______________________________________________________________________________________
Do you have any medical conditions? Yes 
No 
If so, what are they?______________________________________________________________________________________
Do you have any food restrictions? Yes 
No 
If so, what are they?______________________________________________________________________________________
Do you like pets? Yes 
No 
Do you have any other preferences that we should know about?____________________________________
_____________________________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Please give details of someone we can contact in an emergency while you are in Porto Alegre:
Name______________________________________________________________________________________________________
Telephone number_______________________________________________________________________________________
Contact address__________________________________________________________________________________________
_____________________________________________________________________________________________________________
Email____________________________________________________Skype name____________________________________
STUDENT DECLARATION
I hereby submit my application for the Portuguese and Community Service Program as
indicated above. I agree that the information on this application form is true. I have read and
understood the information provided here and on the abovementioned website and fully
accept the terms and conditions. Applications cannot be accepted without a signature.
Signature_____________________________________________________________________Date_______________________
Campus Central
Av. Ipiranga, 6681 – prédio 1 – sala 110 – CEP 90619-900
Porto Alegre – RS - Brasil
Fone: (51) 3320-3660 – Fax (51) 3320 – 3885
E-mail: [email protected]
www.pucrs.br