Name: ____________________________________  ______________________________________
              (last or family)                     (first or personal) 

Gender: ___Male ___Female             Date of Birth: _____/_____/_____            
                                                      Month Date Year
Do you smoke? ___Yes ___No  If yes, are you willing to smoke outside? ___Yes ___No

(Please note that, in some circumstances, we may NOT be able to accommodate you if
you smoke and are unwilling to smoke outside.)
Home Address: ____________________________________________________________________

E-Mail: _____________________ Fax: ___________________ Telephone: ________________

PERSONAL INFORMATION

English Speaking Ability: ___Very Good  ___Good  ___Fair  ___Poor  ___None

Do you have any health problems? (allergies, handicaps, or any physical condition
that requires special attention):
__________________________________________________________________________________

Are you a student? ___Yes ___No  If yes, what is your major? _____________________

If you are not a student, what is your profession? _______________________________
        What do you like to do in your free time? 
__________________________________________________________________________________

Please check any of these activities you enjoy:  ___Reading  ___Movies ___Shopping
___Sports ___Dancing ___Camping ___Music ___Art  Other: __________________________

Do you play any musical instruments? _____________________________________________ 

What kind of music do you like? __________________________________________________ 

Do you like sports? ___Yes ___No  

Which sports do you like to play? ________________________________________________

Do you like to travel? ___Yes ___No

Please list any countries that you have visited: _________________________________

Do you speak any languages other than your native language and English? 
__________________________________________________________________________________

During your stay you will visit an American family. Please answer the following
questions so that we can place you with a family in which you feel comfortable:

Do you want to visit a family that has children?  ___Yes  ___No  ___Not important
If yes, what age children do you prefer? _________________________________________

Do you want to visit a family that has pets?  ___Yes  ___No  ___Not important
Check the animals you DO NOT like: ___Cats  ___Small dogs  ___Large dogs  ___Birds
Other: ___________________________________

Please list any foods that you do not like or cannot eat: ________________________
__________________________________________________________________________________


PERSONAL CHARACTERISTICS:

__Independent  __Cautious  __Quiet     __Talkative   __Serious  __Tidy  __Athletic 
__Energetic    __Humorous  __Studious  __Sociable/Outgoing    Other:______________

Do you go to bed early at night?  _____Yes   _____No 
Do you sleep late in the morning? _____Yes   _____No

Do you have any special requests or concerns about living in a residence hall or 
visiting an American family?
__________________________________________________________________________________

__________________________________________________________________________________

Describe yourself. Include information about your family, likes/dislikes, hobbies, 
interests, etc.:
__________________________________________________________________________________

__________________________________________________________________________________

Do you have a relative or friend living in the United States? Please list 
his/her address and telephone number below:

Name: ____________________________________________________________________________

Address: _________________________________________________________________________

Telephone: _______________________________________________________________________