Please type or print legibly in black ink, so that these forms can be photocopied.
Answer all questions. Please complete this application as honestly as possible.
Our organization will use this information to select your host family.
STUDENT INFORMATION
Legal name (as it appears on your passport)
Last name: __________________________
First name: _________________________
Middle name: _______________________
Nickname: __________________________
Sex: Male Female
Address
Address: ______________________________
City/Town: ____________________________
State/Province: _________________________
Zip Code/Postal Code: ___________________
Telephone:_____________________________
Area/City Code
Home Fax: ____________________________
Area/City Code
Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec _____________
Month (circle one) Day Year
Place of Birth: __________________________________________________________________
City/Town State/Province
Country of Citizenship: ______________Country of Permanent Residence: