Family Name   First Name   Date of Birth 

 Gender        Male        Female       

Address        

City                   Country     Postal Code

Home Phone    (country code – city code – number)     

Fax                  (country code– city code – number)

Email            

Program Information

Name of Program          Date of Program 

Arrival Date                 Departure Date      

Housing Preferences (You must select two of the options below)

    Homestay with American Family (Breakfast and dinner included)

    Private bedroom                 

    Shared bedroom (subject to availability)

    Rent a room in American home (Food not included)

Personal Information

The following information will help us place you in a room or a home that best meets your needs.

Name of the person you would like to be housed with if any 

Hobbies

Personality

  Shy                     Outgoing                      Other  

Do you have any allergies?           - - - Yes No    Please Specify 

Do you smoke?               Yes     No

Do you drink alcohol?    Yes     No

Do you plan to have a car during your studies here?      - - - Yes No

(Note: Certificate Programs students must have access to a car)

May we place you in a home with children age 8 and under?     - - - Yes No

May we place you in the home with a student of the opposite sex? (You will not be placed in the same room, but may share a bathroom)

- - - Yes No

Signature                                                  Date