_______________________________________________________
Applicant Name: Family Name
First
Middle
Date of Birth: Month ___________ Day _____ Year _____ Sex: o Male o Female
_______________________________________________________________________
Address in Your Country:
Number and Street
_______________________________________________________________________
City
Postal Code
_____________________________________________(______)___________________
Country
Phone
Number (include city code)
E-mail Address: ________________________________________________________
_______________________________________________________________________
Parents' Names
_______________________________________________________________________
Parents' Address:
Number and Street
_______________________________________________________________________
City
Postal
Code Country
1. _____________________________________________________________________
Student's Country of Citizenship
Country of
Birth
2. If already living in the U.S., how long?
______________________________________
Type of visa you have or want?
____________________________________________
3. What are your career goals? (e.g., doctor, teacher) ____________________________
4. When will you arrive? ____________ How long do you plan to stay? ______________
5. Do you have a racial preference for your American family?
o Asian o African o
Caucasian o Hispanic
6. How long do you wish to live with your American family? ________________________
7. Are you planning any special excursions while in the USA?
_____________________
Where?
________________________________________________________________
8. Do you speak English? o No o Fair o Good o Fluent
9. Last grade level completed in your country?
__________________________________
Favorite subjects
________________________________________________________
10. Do you smoke or use any tobacco? o No o Yes ____________________________
Do you ever use any drugs? o No o Yes
__________________________________
11. Do you drink alcoholic beverages? o Never o Occasionally o Frequently
12. Religious preference: o Christian o Buddhist o Shinto o Moslem o Other
13. List medical restrictions and considerations: __________________________________
14. Will you have a car while here? _______ If not, we will try to find a
home near school
or near a bus line.
15. What activities do you enjoy? ______________________________________________
16. What is your musical preference? ___________________________________________
17. Do you play a musical instrument? _______ Which one(s)? _____________________
18. Please enclose a copy of your medical insurance policy for our files.
19. Be aware that if you own and drive a car in Texas, it is mandatory that you
have
liability insurance on the automobile. You
must have an International driver's license
or a Texas driver's license to drive a car in Texas.
20. In case of emergency, who do we contact? ___________________________________
Phone: ______________ Address:
__________________________________________
I hereby apply to Homestay, Center of English Language, to find a suitable home for me. I have enclosed a $100.00 non-refundable fee. I understand that all other fees must be paid in advance, before I go to my host home.
_____________________________________
Date
____________________________________
____________________________________
Signature of Student
Signature of Parent or Guardian
(if
student is under 21)
____________________________________
____________________________________
Print Name
Print Name
