Homestay Application Step 1 of 4 25% CityWashington DCBostonLos AngelesNew YorkCleveland, OhioSan DiegoSan FranciscoName* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Marital Status Single Married Divorced Country of Citizenship Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Place of Birth* Email* Enter Email Confirm Email PhoneFaxEmergency ContactEmergency Contact Name Relationship Emergency Contact PhoneEmergency Contact Email Profile InformationEnglish Level Beginner Intermediate Advanced Languages Spoken Occupation Religion Type of Visa Visitor Student Interests and HobbiesHow would you describe your personality? Check all the boxes that describe you: Quiet Shy Messy Open-minded Outgoing Independent Tidy Cautious Religious Cheerful Frugal Organized Private Talkative Athletic Energetic Noisy Picky Eater Serious Nervous Calm Other Please describe: Do you smoke? Yes No Have you ever participated in a homestay? Yes No Are you allergic to pets? Yes No Please specify: Cats Dogs All Have you ever been convicted of a crime? Yes No Please explain: What would you like to gain from your homestay experience?How did you hear about our program?Please write a brief note to your host family, describing what you would like them to know about you: Health InformationDo you consider your health to be: Excellent Good Fair Do you have any medical problems we should know about? Yes No Please explain: Do you have medical insurance? Yes No Would you like to receive insurance information? Yes No Do you have any food allergies or restrictions? Yes No Please explain: Do you have any other allergies? Yes No Please explain: Have you participated in therapy or counseling in the past two years? Yes No Please explain: Housing OptionsHow many months will you need housing? What is the expected homestay begin date? MM slash DD slash YYYY What is the expected homestay end date? MM slash DD slash YYYY Select your meal plan: Bed & Breakfast Standard Deluxe Indicate your family size preference: 1-3 members 4 or more No preference Can you live with children under 10? Yes No Can you live with a smoker? Yes No Private Bath ($60 Additional for Standard Homestay) Yes No School InformationEnrollment Start Date MM slash DD slash YYYY Enrollment End Date MM slash DD slash YYYY Name of School Location (City, State) Travel InformationArrival Date MM slash DD slash YYYY Arrival Time : Hours Minutes AM PM AM/PM Airport Airline Flight Number Flight Origin Do you require airport pickup? Yes No Will you have the use of an automobile? Yes No ReservationTo reserve your accommodation, we require a one-time, non-refundable placement fee of $195. This fee guarantees your placement. You may pay your placement fee by credit card, wire transfer or bank draft. Once you submit this form, we will contact you to make payment arrangements.By clicking below, you are certifying that the information provided above is complete and accurate. You are also acknowledging that you have read and understood our legal notices, and that you are at least 13 years old. Δ
