Are you ?

Read and check the box below. Then press the "Submit Application" button
(OR)
Please read and sign below. Then fax this form to: 858-605-1267



By checking "YES" I hereby certify that the foregoing is true and correct to the best of my knowledge and agree, to hold harmless Foreign Student Homestay, its owners and agents, from any claim by me for losses, costs, expenses, damages or injuries to persons or property, whether direct or in direct, or consequential, arising in any way out of any housing arrangement made between myself or anyone representing me and Foreign Student  Homestay, including any activity related to such housing arrangement or agreement.
                    

Private Bedroom ( Breakfast & Dinner included )
Housing  Preferences
( the following information helps place you in a suitable environment )
Personal Information
Personality Information
Homestay  Application
Program Information
Date of Program:
Arrival Date:
Departure Date:.
Family Name
First Name
Date of Birth
Gender
Address
City
Country
Postal Code
Home Phone
country code / city code / number
Fax Number
E-Mail
country code / city code / number
Do you have any allergies ?
If "Yes" please explain
May we place you in a home with children under 8 years old ?
Do you smoke ?
Do you drink alcohol ?
Do you plan on having an automobile during your studies here ?
( Note: Certificate Programs require students to have access to an auto )
May we place you in a home with a student of the opposite sex ?
( You will not be placed in the same room but may share a bathroom )
Are you ?
Hobbies
Name of Program
Do you have a known medical condition ?.
If "Yes" please explain
Shared Bedroom ( Meals Included /  subject to availability )
Rent a room in an American home  ( meals not included )
Signature
Date
MaleFemale
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Shy
Outgoing
Other
Yes
Yes
Yes
Yes
No