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3
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5
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7
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Angola
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Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
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Mayotte
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2) Parents orGuardian Email Address
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Chile
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Christmas Island
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Cook Islands
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Cuba
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Lesotho
Liberia
Libya
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Malaysia
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Mali
Malta
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Mayotte
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Montserrat
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Mozambique
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Nagorno-Karabakh
Namibia
Nauru
Nepal
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Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
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Switzerland
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Tanzania
Thailand
Timor-Leste
Togo
Tokelau
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Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Emergency Contact Email Address
Relationship
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Placement Info
Do you have any medical condition, physical condition or allergies that will limit your activities during the program?
Yes
No
If yes, please provide detailed information
Are there any pets you can not live with?
Yes
No
If yes, please provide detailed information
Do you have any special dietary restriction?
Yes
No
If yes, please provide detailed information
If you are a vegetarian / vegan, are you willing to eat?
Fish
Poultry
Dairy Products
Others
If Others, please provide detailed information
What is your religion?
Do you require participating in religious services?
Yes
No
If Yes, please provide detailed information
Do you smoke?
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No
If yes, are you willing to stop smoking during your program?
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No
What is your native languague?
Do you speak any other languages?
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No
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Speaking Ability
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Introduction
Please attach photos showing you, your friends, and family; add a small phrase to describe it.
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Photo 3
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Photo 4
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Photo 5 (Passport Color Scan)
What are your major interests and hobbies?
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Please, use this field to describe yourself or write an introduction letter to you host family.
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DISCLAIMER XPERIENCES Staff will do the best effort to place you according to all the requirements specified above but may not be able to succeed in all the fields. By digitally signing this; you certify that you are aware that a perfect location in a host family is not guaranteed. I accept and compromise to obey all rules, directions and orders from all XPERIENCES Team Members and Directors, must compromise to them and respect them at any time during my participation and stay in the host country. I am aware all illegal activity or action done by me during my participation or stay in the host country is my sole responsibility and separates XPERIENCES, XPERIENCES Team Members and Directors of any legal action taken against me.
Accepted
Participant Name
Participants Digital Signature (Please write your initials)
Parent / Guardian Name
Parent / Guardian Digital Signature (Please write your initials)
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