Family Name:
First Name:
Phone:
Present Address:
City:
State/Province/Prefecture:
Zip/Postal Code:
E-mail:
(required)
Parent's Address:
City:
State/Province/Prefecture:
Zip/Postal Code:
Date of Birth:
Male:
Female:
Nationality:
Destination 1:
Arrival Date:
Departure Date:
Destination 2:
Arrival Date:
Departure Date:
Are you travelling by... Bus:
Train:
Plane:
Other:
Father's Name:
Occupation:
Mother's Name:
Occupation:
Brother's & Sister's: Brothers
Sisters
How Many?
Ages
Name of your School:
Major
Grade:
Career Interest:
Who who referred you to us:
Phone:
Interests/Hobbies/Sports:
Previous Trips Abroad:
Have you participated in a Homestay Program before? Yes:
No:
Personality: Outgoing:
Shy:
Independent:
Quiet
Energetic:
Sociable:
Optimistic:
Cheerful:
Tidy:
Serious:
Talkative:
Modest:
Adventurous:
Affectionate:
Curious:
Others:
Do you smoke? Yes:
No:
Do you drink alcohol? Yes:
No:
Do you like animals?: Yes:
No:
Are there any foods that you cannot eat?:
What do you hope to learn from your Homestay?:
Name of your Insurance Company:
Name any Allergies you have:
Name any Drugs you must take regularly:
Present Condition of your Health:
Excellent
Good
Fair
Poor
Name of Local Person to Contact in Case of Emergency:
His/Her Address:
Phone: