Homestay Application Step 1 of 4 25% CityWashington DCBostonLos AngelesNew YorkCleveland, OhioSan DiegoSan FranciscoName* First Last Date of Birth* Gender*MaleFemaleMarital StatusSingleMarriedDivorcedCountry of CitizenshipAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Place of Birth*Email* Enter Email Confirm Email PhoneFaxEmergency ContactEmergency Contact NameRelationshipEmergency Contact PhoneEmergency Contact Email Profile InformationEnglish LevelBeginnerIntermediateAdvancedLanguages SpokenOccupationReligionType of VisaVisitorStudentInterests 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?YesNoHave you ever participated in a homestay?YesNoAre you allergic to pets?YesNoPlease specify:CatsDogsAllHave you ever been convicted of a crime?YesNoPlease 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:ExcellentGoodFairDo you have any medical problems we should know about?YesNoPlease explain:Do you have medical insurance?YesNoWould you like to receive insurance information?YesNoDo you have any food allergies or restrictions?YesNoPlease explain:Do you have any other allergies?YesNoPlease explain:Have you participated in therapy or counseling in the past two years?YesNoPlease explain:Housing OptionsHow many months will you need housing?What is the expected homestay begin date? What is the expected homestay end date? Select your meal plan:Bed & BreakfastStandardDeluxeIndicate your family size preference:1-3 members4 or moreNo preferenceCan you live with children under 10?YesNoCan you live with a smoker?YesNoPrivate Bath ($60 Additional for Standard Homestay)YesNo School InformationEnrollment Start Date Enrollment End Date Name of SchoolLocation (City, State)Travel InformationArrival Date Arrival Time : HH MM AM PM AirportAirlineFlight NumberFlight OriginDo you require airport pickup?YesNoWill you have the use of an automobile?YesNoReservationTo 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.