SSILC

>	Student Application Form
>	Become a Host Family

HOMESTAY APPLICATION FORM

Personal Information

First Name:

Last Name:

Birth Date:

Gender:

Female

Male

Nationality:

Location & Contact information


Address:
Postal Code:
City:
State:
Country:

Phone #:
Fax #:
e-mail:

Emergency Contact Information


Name:
Relationship:
Phone #:

Name:
Relationship:
Phone #:

School Information


Name:
Address:
Phone #:

Start Date:
End Date:

Accommodation Information

Meal plan:

3 Meals

2 Meals

NO Meals

YES

NO

Do you smoke?

Do you drink alcohol?

Do you prefer a family with children?

Do you prefer a family with cats?

Do you prefer a family with dogs?

Do you have special food requirements?

Do you have any allergy?

Do you have a medical condition?

Do you have Medical Insurance

	Homestay Start Date:
	Homestay End Date:

Flight Information

Arrival Date:

Arrival Time:

Airline:

Flight #:

Arrivng from:

Visa Status:

Airport Pick-Up:

Yes

No

Airport Drop-Off:

Yes

No