Last Name

First Name

Age

Date Of Birth mm/dd/yyyy

Gender Gender Male Female

Marital Status Marital Status Single Married Divorced

Spouse Name

Street Address

City

State/Province

Country

Email Address

Home Phone Number

Cell Phone Number

FAX

Nationality

Native Language

Other Languages

Homestay Start Date mm/dd/yyyy

Homestay End Date mm/dd/yyyy

Do you plan to have a car during your stay? Do you plan to have a car during your stay? Yes No

Please rate English conversation Ability Please rate English conversation Ability Low Intermediate Advanced

Do you smoke? Do you smoke? Yes No

Would you be comfortable in a home that permits smoking? Would you be comfortable in a home that permits smoking? Yes No

Would you be comfortable in a home that permits alcohol? Would you be comfortable in a home that permits alcohol? Yes No

Would you be comfortable in a home with young children (under 6 years)? Would you be comfortable in a home with young children (under 6 years)? Yes No

Would you be comfortable in a home with pets? Would you be comfortable in a home with pets? Yes No

Dog Dog Yes No

Cat Cat Yes No

Do You have a Food Allergy or food issues? Do You have a Food Allergy or food issues? Yes No

Please list any allergies or health problems your host will need to know about. Please list any foods you cannot eat due to allergies, health problems, or personal beliefs. (Enter List of: allergies, health problems, and foods you cannot eat here.)

If you practice a religion, what is your faith?

Please list your current hobbies.

Which school do you plan to attend? (School Name)

School/Campus Address

School/Campus City

What schools have you attended in your past course of studies? Include other language schools and their locations.

Degree, Certificate, Diploma

Year Of Graduation

2nd Degree, Certificate, Diploma

2nd Year Of Graduation

3rd Degree, Certificate, Diploma

3rd Year Of Graduation

Describe what you are currently doing in your country.

What are your career interests and future plans of study?

Please tell us about your family. (ex. How many family members, ages, and occupations)

Is there anything else you would like to say about yourself and your homestay expectations?

Emergency Contact Name

Emergency Relationship (Ex. Father, Spouse, Sibling)

Emergency Phone Number

Emergency Country

Emergency Contact Email

Additional US Emergency Contact Name

US Emergency Relationship

US Emergency Phone

US Emergency Address

Emergency City

Emergency State/Province

US Emergency Contact Email

Airline

Flight Number

Arrival Date

Arrival Time

Please indicate if you wish an airport greeting Please indicate if you wish an airport greeting Yes No

We offer airport greeting service from San Diego airport: Within the immediate San Diego City area - $75.00. North San Diego area: $125.00. In most cases students are met at the gate, or near the baggage claim. You receive a warm greeting by a Home Placement Services, Inc. employee at the airport, assistance with your baggage, transportation by private car to your HomeSsay, and an introduction to your Host Family. We offer airport greeting service from San Diego airport: Within the immediate San Diego City area - $75.00. North San Diego area: $125.00. In most cases students are met at the gate, or near the baggage claim. You receive a warm greeting by a Home Placement Services, Inc. employee at the airport, assistance with your baggage, transportation by private car to your HomeSsay, and an introduction to your Host Family. I Understand and have compleated all of the above