Personal Information

First Name: Last Name:  

Email:   

Local Telephone Number:

Date of Birth:   mm/dd/yy

Gender:  

Country of Origin:  

Language(s) You Speak:  

Duration of Stay:  

Major:  

Student Status: --Select-- Undergraduate Graduate

List Any Dietary Needs:
 

Do you smoke? --Select-- yes no  

What is your religious affiliation?
(Optional, may be considered in matching with family indicating preference.)

Are you married? --Select-- yes no   Is your Spouse with you? --Select-- yes no

List activities and hobbies you enjoy:

Host Family Preferences

Please indicate your preferences in the following categories about your host family:

• Smoking/Non-Smoking: --Select-- Non-Smokers Smokers No Preference  
• Married/Single: --Select-- Married Single No Preference  
  
• Children/No Children: --Select-- Children No Children No Preference  
  

List any preferences or objections to the host family’s religious affiliation:

Other Information

How frequently do plan to meet with your host family (i.e. once a week, bi-monthly, monthly, etc.)?  

Please select the activities you enjoy participating in:

• SPORTS
  

  Aerobics     Cycling     Horse Riding     Racquetball     Soccer     American football     Darts     Hunting     Roller skating     Swimming     Archery     Down hill skiing     Ice fishing     Rollerblading     Tennis     Basketball     Field hockey     Ice skating     Running     Volleyball     Baseball     Fishing     Martial Arts     Sailing     Water skiing     Bowling     Golf     Mountain climbing     Skydiving     Windsurfing     Camping     Hiking     Ping‐pong     Snowmobiling     Weight lifting     Cross country skiing     Horseshoes     Pocket pool     Snow sledding     Wrestling

   
  
• ARTS
  

  Attending the Theater     Cooking     Musical Instuments     Opera     Attending The Symphony     Drama     Painting     Visiting Museums     Choir     Dancing     Photography     Writing

   
  
• OTHER
  

  Backgammon     Going to Movies     Shopping     Reading     Chess     Picnics     Trying new foods     Watching TV     Discussing Current Events     Sewing     Traveling     Watching Sports

   
  

List activities you would like to participate in with your host family:
 

List any other information you feel is relevant or important in the matching of your host family (allergies, fears, strong dislikes).