Student Online Application Form Student Profile & Application Personal Details The dates for which you are applying for Homestay: (dd/mm/yyyy) From: To: Type of Visa entering the United States: First Name: Last Name: Gender: selectmalefemale Date of Birth:(dd/mm/yyyy) Country of Origin: Home Address (complete): Student’s Native Language: Primary Language Spoken in your Home: Student’s Cell Phone: Student’s Email: Do you smoke? selectNoYes Could you live in a home with someone who smoked (outside)? selectYesNo Do you have any health problems? selectNoYes If yes, Please specify: Do you have any allergies to pets? selectNoYes If yes, Please specify: Are you taking any medications? selectNoYes If yes, Please specify: Do you have health insurance that is valid in the USA? selectYesNo If yes, Please specify Company name and Policy # Emergency Contact: Relationship to Student: Cell Phone: Work Phone: Personal Characteristics:(please select all that apply) CautiousEnergeticHumorousIndependentModestQuietShySociable / OutgoingStudiousTalkativeTidy What type of home do you prefer? selectActiveQuiet Will you accept living in a home with a family’s other children? selectYesNo Will you accept living in a home with pets? selectYesNo Would a host family's religious views be a factor in your decision to live with them? selectNoYes Would you prefer a TV in your room? (not always available) selectNoYes Do you have Special requirements? selectNoYes If yes, Please specify: What are your hobbies? Do you have any food allergies? What do you enjoy eating for breakfast? What do you enjoy eating for dinner? Is there any food that you do NOT enjoy eating? Would you require transportation to school? selectYesNo Would you be willing to take public bus transportation to school? (if available) selectYesNo Travel Details Airline: Flight #: USA Connecting Airport to Florida Airport: Florida Arrival Airport: selectFt. LauderdaleMiami Florida Arrival Date: (dd/mm/yyyy) Florida Arrival Time: School Details How did you hear about Homestay Florida’s International Student Program? Have you lived in homestay in the United States before? If yes, then please provide details. What school will you attend?please select one selectAmerican Collegiate Academy (Clearwater, FL)Bishop Verot Catholic High School (Ft. Myers, FL)Community School of Naples (Naples, FL)St. John Neumann Catholic High School (Naples, FL)The Sagemont School (Weston, FL)OTHER Other: What date does school begin? (dd/mm/yyyy) What are your class hours? Additional comments: We expect all of our homestay students to be courteous and respectful while living with our host families. Please provide two character references. These must be personal, non-familial references who have known you for at least five years. Declaration "I verify that the information on this form is true and correct to the best of my knowledge." Electronic Signature & Date