Last Name First Name English Name
Birth Date Email Phone Cell Phone Grade Entering Gender Nationality
Home Address City Country/Province Zip Code
Father Mother
First Name:
Last Name:
Street Address:
City:
Country/Province:
Postal Code:
Country Phone:
Cell Phone:
Email:
Occupation:
First Name:
Last Name:
Street Address:
City:
Country/Province:
Postal Code:
Country Phone:
Cell Phone:
Email:
Occupation:
  AGENT INFORMATION:
Company Name
Name 1 Name 2
Business Phone Business Phone
Cell Phone Cell Phone
Email 1 Email 2

Address City
Country/Province Postal Code
  GUARDIAN INFORMATION: Guardian must speak English and be a California Resident
First Name Last Name
Business Phone Email
Cell Phone

Address City
Country/Province Postal Code

  PROVIDE THE FOLLOWING INFORMATION ABOUT YOURSELF:
English Ability:       Excellent       Good       Fair       Poor
Will it bother you if there are young children (ages 0-4) in the house:       Yes       No

Will it bother you there are animals in the house:       Yes       No


Degree of participation in church related activities:       Active       Average       Little Interest       Inactive       No Interest

How often do you attend church services:       2x+ a week       1-2x a week       Occasionally       Never Attended

Would you attend services with your Host family if they were different from your own:       Yes       No

Will you have a car in the USA:       Yes       No

Be advised, there is a no smoking policy for all of our homestays
Do you smoke cigarettes:       Yes       No


Check any of the following that best describes you:

  PLEASE RANK THE FOLLOWING STATEMENTS BY CHECKING THE RESPONSE AS THEY PERTAIN TO YOU:
I use computers all the time:
Strongly Disagree       Disagree       Neutral       Agree       Strongly Agree

I enjoy watching and/or participating in sports:
Strongly Disagree       Disagree       Neutral       Agree       Strongly Agree

I enjoy outdoor activities:
Strongly Disagree       Disagree       Neutral       Agree       Strongly Agree

At mealtime I enjoy eating new/different foods:
Strongly Disagree       Disagree       Neutral       Agree       Strongly Agree

I enjoy spending time with family and/or friends:
Strongly Disagree       Disagree       Neutral       Agree       Strongly Agree


  PROVIDE THE FOLLOWING INFORMATION ABOUT YOUR ACTIVITIES:
Do you play a musical instrument:       Yes       No

Do you play the piano:       Yes       No

Can you swim:       Yes       No

Do you play in any team sports:       Yes       No





  PROVIDE THE FOLLOWING MEDICAL INFORMATION:
Are you allergic to cats:       Yes       No

Are you allergic to dogs:       Yes       No

Are you allergic to any food(s):       Yes       No

Do you have any other allergies:       Yes       No

Do you have any pre-existing medical conditions or any medical concerns that your Host family should know about:
      Yes       No

Are you in good health:       Yes       No

Do you have any dietary restrictions:       Yes       No

Are you a Vegetarian:       Yes       No

Do you have any special dietary requirements (i.e., no dairy, no pork, keep kosher):       Yes       No

  SCHOOL:
Have you been accepted to this school:       Yes       No