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  Homestay Application Form
1. Name of Student:
2. Date of Birth:
3. Age:
4. Phone Number:
5. Gender:___ Male ___ Female
6. Home Address:
7. Fax Number:
8. E-mail Address:
9. Current or most recent school / Company:
 Address:
 Phone Number:
10. Major / Occupation:
11. Name of Parent / Sponsor:
Address:
 Phone Number:
 Relationship:
12. Please provide information about your family members:

 Name of Family Member

Age

Occupation

Relationship
       
       
       
       
       
       
       
 13. English Ability: ___ Beginning ___ Intermediate ___ Advanced
14. Will you need airport pick-up service at the Los Angeles International Airport? ____Yes. Arrival Date:__/__/__ Arrival Time: ________
Carrier and Flight Number: _________________________
___ No.
15. Move-in Date: ____/____/____  Expected Length of Stay:_______________
16. Name of Insurance Company (if available)  ________________________________

17. Do you smoke?

Do you accept not to smoke inside the house?

Can you stay with a smoking family?

___ Yes.____ No

___ Yes ___ No.

___ Yes ___ No

18. Do you drink alcohol? ___ Very often. ___ Sometimes ___ Not at all.
19. Will you live with a family that has small children (under age 10)? ___ Yes ___ No
20. Will you live with a family that has a dog or cat? ____ Yes ___ No
21. Do you have any allergies? ___ Yes ___ No
22. Do you take any medications regularly? ___ Yes Which? ________________
___ No.
23. Do you have any special food needs? ___ Yes ____ No
24. What are your hobbies? ______________________________________________ ______________________________________________ ______________________________________________
25. Please let us know if you have any special requests or any other necessary information
about yourself:		 ______________________________________________ ______________________________________________ ______________________________________________
26. On a separate page, please write short essays in English about the following:
· An introduction of your self and your family
· Your reason for requesting home stay
· Your educational background and/or educational and career goals
· Any subject that you think your host family would like to know about your personal life or lifestyle?
 Rules and Regulations:
1. My parent(s) agree that the host parent can take me to a hospital when I need any medical
attention.
2. I agree to leave my host home when I complete my schooling.
I certify that all the information I give on this application form is true and corret.
 Signature of Applicant: ______________________________________ Date:_________
 Signature of Applicant’s parent (if applicant is under 21 years old):
________________________________________________________ Date: _________

 Print this form, fill it out completely, and fax it to us at 001-213-381-6721.

Questions? Ask us!