EmailMe Form - HOMEXCHANGE STUDENT APPLICATION

PERSONAL & CONTACT INFO

Name *

First Last

Email *

Phone *

### - ### - ####

Physical Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

What is your home country and city? *

Age *

Birthday *

MM / DD / YYYY

Gender *

Male

Female

Marital Status *

Single

Married

Divorced/Widowed

Spouse's Name

First MI Last

Children

Include the names, ages, and gender of your children.

Example:
Joe, 2 yrs old, boy
Maryam, 4 1/2 yrs old, girl

HOMESTAY DETAILS

We will use this information to help find a suitable host.

No. of individuals for Homestay *

Including yourself, how many people from your family would live together with the Host Family?

What date would you like to start your homestay? *

MM / DD / YYYY

What date would you like to end your homestay?

MM / DD / YYYY

What language/culture would you like to focus on? *

How much experience do you have in your target language/culture? *

No experience

Some informal experience and/or relationships

One year or less of formal training/education

One to two years of formal training/education

Two to three years of formal training/education

More than three years of formal training/education

Do you smoke? *

Yes

No

Occasionally, for recreation

Do you have any pet allergies or fears? If yes, please indicate which animals. *

Do you have any physical or medical needs your host should know about? If yes, explain. *

Do you have any dietary needs, allergies or restrictions? Please explain. *

What are your hobbies and interests? *

What do you hope to gain from your homestay experience? *

What would you like your homestay host to know about you?

EDUCATION & EMPLOYMENT HISTORY

Education *

Please include the name(s) of your school, dates of attendance & diploma/degree/certificate information for current and previous schools (high school and above).

Employment history *

Please include your Employer name, dates of employment, job title & job duties for your current and previous jobs.

REFERENCES

Please provide the name, email and phone number of two references we can contact.

Reference One *

Reference Two *

SOCIAL MEDIA

Please share any of your social media profiles (or websites) you'd like, where we can connect with you and get to know you better (e.g. Facebook.com/johndoe; Instagram.com/johndoe; etc.). **We will not share this information.**

Social Media Profiles

Facebook, Instagram, Twitter, Wordpress, personal website, etc.