homestay application

STUDENT HOMESTAY APPLICATION WINTER IMMERSIONPlease type or use a black or blue pen to complete the application. Full Legal Name: ____________________________________________ Nickname: _______________________________ Date of Birth (mm/dd/yyyy): ________________________ Place of Birth: ______________________________________ Passport Number: _____________________________________ Passport Expiration Date: ________________________ Home Address: _____________________________________________________________________________________ City: ________________________________ State/Country: ________________________ Postal Code: ______________ Home Phone Number: _______________________________ Mobile Number: __________________________________ Email Address: ______________________________________________________________________________________Student Lives With: Both Parents Mother Father Other: ________________________________ FAMILY INFORMATIONFather’s Legal Name: ________________________________________________________________________________ Occupation: ______________________________________ Work Phone Number: ______________________________ Email Address: _____________________________________________ Mobile Number: __________________________ Mother’s Legal Name: ________________________________________________________________________________ Occupation: ______________________________________ Work Phone Number: ______________________________ Email Address: _____________________________________________ Mobile Number: __________________________ PERSONAL DATAWhat are your interests and hobbies (e.g. crafts, reading, cooking, music, etc.)? _________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ What sports do you participate in? _____________________________________________________________________ __________________________________________________________________________________________________What are your favorite subjects in school and why? ________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ List foreign languages you have studied:Do you have pets at home? YES NO If YES, how many and what type: _________________________________ Are you allergic to any animals? YES NO If YES, which animal(s): ______________________________________ Do you smoke? YES NO OCCASIONALLYIt is against program rules for NISE students to smoke during program.Do you attend religious services in your country? YES NOHow often? _____________________________ Religious Affiliations: _________________________________________ Do you have any allergies to foods and/or medications? YES NOIf YES, please specify: ________________________________________________________________________________ Are you taking any medications? YES NOIf YES, please specify: ________________________________________________________________________________ If bringing medication from your country, NISE needs information as to what it is.Do you have any pre-existing health conditions? YES NOIf YES, please list and explain: __________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Failure to list pre-existing health condition(s) not covered by the international travel and medical insurance and will lead to early program termination. The student’s natural parents/legal guardians will be responsible for any and all fees not covered by t he insurance and early repatriation. No refunds will be processed for students terminated early from the program.Do you follow a special diet (e.g. vegetarian, vegan, etc.)? YES NOIf YES, please specify: ________________________________________________________________________________ Will you require modification of proposed activities due to religious beliefs or physical restrictions? YES NO If YES, please specify: ________________________________________________________________________________ __________________________________________________________________________________________________。