International Student - Application for Homestay

International Student - Application For Homestay

◄ STUDENT INFORMATION ►

NAME: ______

Surname (Family Name) Given Name

DATE OF BIRTH: _____/____/____ SEX:  Male

Day Month Year  Female

ADDRESS: ______

______

______email address:______

FAMILY MEMBERS:

Name / Relationship / Age / Occupation

CHARACTER:

 Outgoing  Studious  Quiet  Energetic  Independent

 Shy  Adaptable  Considerate  Cheerful  Sociable

  Other:

______

DISLIKES:

Food: ______Animal: ______Other: ______

______

APPLICATION FOR HOMESTAY 2

HEALTH: (Please specify)

Allergies ______

Past Illnesses / operations ______

Any other chronic conditions, e.g., asthma ______

Special medication being taken ______

Smoker  Non-Smoker 

PREFERRED CHARACTERISTICS OF HOMESTAY FAMILY:

 No children  Young children  Same age children  Retired couple

 Pets  No pets  No preference

  Other:______

RECREATION AND HOBBIES: ( Please specify)

Sports ______

Listening to music ______

Playing a musical instrument ______

Games ______

Other e.g., reading ______

______

EMERGENCY:

In case of emergency please contact / notify:

Name: ______Relationship: ______

Address: ______Telephone No.: ______

______Fax No.: ______

______

REMARKS:

SIGNATURE: ______

Student Parent