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Homestay Program Student Information

Homestay Program Student Information Form:

Your Last Name (Family name)

Your First Name (Given name)

Age (Years Old)

Date of birth (Year-Month-Date)

Gender

Your Telephone number

Your Email (required)

Where do you live? "I am living at:"
Home (with parents)DormitoryHome or apartment by myselfHome or apartment with friends or sibling other than your parents.Other

Your Home (Permanent) Address

Guardian's Name 1: (Example: Father)

Occupation:

Guardian's Name 2: (Example: Mother)

Occupation:

*** Emergency Contact Information ***
Emergency Telephone Number:

Emergency Email:

Your Relationship to this Emergency Contact:

Do you have brothers or sisters?
Name of brothers or sisters:
Age:
Age:
Age:
Age:

Name of your attending school:

Your major/focus of studies/department:

Fluency in English:

English certifications, exam scores:
Choose:TOEFL(iBT), TOEFL(CBT), TOEFL(PBT), TOEIC, IELTS, TSE, iTEP, TEPS, STEP-Eiken,
Other


Your score:

Years of English study:

Hobbies, personal interests:

Do you smoke?

Are you vegetarian?

Is there food you cannot?

Conditions of your health:

Do you take any prescription medicine?

DO YOU HAVE ANY PRE-EXISTING HEALTH CONDITIONS? (If yes, please explain) YES NO
List any pre-existing medical conditions and any major illnesses, injuries, and operations that the Applicant (or Student) has undergone in the past 6 months.

APPLICANT (OR STUDENT)’S LETTER TO HOST FAMILY
In the space below, please write a letter to your host family explaining yourself, your family, and your interests.
You may also want to include:
1) What you expect to learn and do during our stay in Oregon.
2) What kind of activities and relationships you hope to have with your host family.
3) How your international experience will make a better world to live in.
The more information you give, the easier it will be for us to match you with a host family. It will also help your family get to know you.

Your Letter

APPLICANT (OR STUDENT) PHOTO ALBUM
Please place photos of yourself and your family in the places you live or frequently go, doing the things you normally like to do. These photos are for your host family, so we encourage you to include those photos which best express yourself and surroundings.

Photo 1 Upload your family photo by clicking "Browse" button to select the photo:

Photo 2 Upload your house photo by clicking "Browse" button to select the photo:

Subject

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