Form

Basic Information
First Name*
Family Name*
American Nickname*
What do you prefer to be called?
Gender*

Male Female
Age*
Email*
U.S. Information
Name of School*
U.S. Address
City
State
U.S. Telephone
Cell phone
College Major
Career Goals
Home Information
Home Country*
Home Address
Person to Contact in Case of Emergency
Name
Relationship to You
Phone Number
Personal Information
Date of Birth
- Month - Day Year
at
/ Hour Minutes
Languages you speak
Religion
How well do you speak English?*
Favorite American foods
What are your interests/hobbies?
Tell us something about yourself
Host Family Preferences
(Check all that apply)
Would you enjoy staying with a host family that...

has small children under age 10 lives in a country area has older, teenage children is an older, retired couple with no children lives in a small town
Some host families have pets or farm animals. Please check if you would NOT like to be with these animals

dog cat bird hamster, mouse, gerbil, or guinea pig farm animals (cow, pig, chicken, goat, etc)
Do you have any health or diet restriction that your host family would need to know?

Vegetarian diet No pork No beef
Should be Empty:

Basic Information