Homestay Application

Release of Liability
The Pacific Language and Cultural Exchange reserves the right to use its own discretion when accepting applicants. Applications that contain false information can be annulled. The Place is not responsible for any damages, claims or loss of life, or personal property arising from a student participating in the homestay program. 

     I have read the above statement     I Accept

Payment Options
You may pay the placement and airport pick up fee by credit card using PayPal, check, or money order.

Please complete the following information

Approximate Arrival Date

Approximate Departure Date

Name
 Mr.  Mrs.  Ms.

First Name               Middle Name       Last Name            

Sex  Male   Female

Mailing Address/Permanent Address

Address    City  

State/Province/Prefecture

Zip Code    Country

Phone   FAX

Email

Date of Birth     Age     Nationality

Passport#

English speaking ability   Very Good    Good    Fair    Poor

Additional Comments

Questionnaire
Do you have any special requirements?  Yes   No  

 Please list special requirements here.

Are you taking any medication?  Yes    No  Explain

Do you have any allergies? Yes    No  Explain

Do you smoke? Yes    No
(It is difficult to find host families who smoke. You may be asked to smoke outside.)

Personal Preferences
Would you like to stay with a host family who has children? Yes    No

Do you like pets? Yes    No

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



What kinds of activities do you like?

How long do you plan to stay? 

Emergency Contact Information

Name     Relation

Address 1   Address 2

City    State/Province/Prefecture

Country     Zip Code

Home Phone (country-city code-number)  

E-mail 

    

     
Homestay placement fee
Price: $300.00 (under 18 years old)
    
Homestay placement fee
Price: $250.00 (adult)		 Airport pick up
Price $60.00