Student Application Form
Host Family Program
PERSONAL INFORMATION
Ms Mr
Name: ... Place, Date of Birth: ...(dd/mm/yy) Nationality:... Address (in home country): ... ... Phone/Fax: ... Mobile Ph... E-mail address: ... In case of emergency, please contact (name, address, phone):... ... ... ... Arrival date (flight no./arrival date & time):... Departure date (flight no./arrival date & time):...
ADDITIONAL INFORMATION
Have you ever been to Indonesia? Yes No Do you speak Indonesian Language? Yes No
If yes, please indicate ...
Beginner Intermediate Advanced
What is your native language?... What other foreign language(s) do you speak?... Have you already stayed in a Host Family? Yes No
Do you mind being in a Host Family with pet(s)? Yes No
What pet(s) do you like and dislike?... ... Do you smoke? Yes No
Do you mind being in a smoking family? Yes No Are you in a good health? Yes No
Is there anything particular we should know in order to select your host family? (dietary restrictions, medical concerns, allergy)...
Please describe yourself by briefly writing about the following
My family
... ... ... ... ... ...
My character
... ... ... ... ... ...
My likes and dislikes
... ... ... ...
My hobbies and interests
... ... ... ...
List any foods you cannot eat and specify the reasons
... ... ... ...
Please write a brief statement about what experience do you hope to have with Host Family Program. Please consider not only what kind of host family you would like to live in, but also how do you plan to participate in and contribute to the crosscultural exchange (Please keep in mind that we will do our utmost to make the best match possible but all that desires cannot always be met) ... ... ... ... ... ... ... ...
Date Name Signature
