Western Illinois University: Macomb Campus

Name

PhoneNumber

Email

Age 

Sex: 
 Male   Female

Major 

Choose a year: 
WESL
Freshman
Sophomore
Junior Senior Graduate Not Student

How did you learn about this program?

List your Interests/Hobbies

How did you learn about this program? 
 Friends 
 Class   Flyer   Facebook   Website   Other

Have you ever been a conversation partner before?
Yes No

If yes, would you like the same partner?
Yes No

What is the person's name?

If yes, can we assign you a partner of opposit sex?
Yes No

Are you more interested in meeting with your partner in a small group setting?
Yes No

If yes, and there is a specific US student you’d like in your group, who?

Please fill in your class and work schedule