IHPS Homestays Application

_I am a (n) Please, Select International Student Applicant ($325 application fee) International Intern/High School Applicant ($475 Application Fee) International Visitor Applicant ($325 application fee) US Citizen Student Applicant ($325) US Citizen Intern ($475)
 

First Name:		Last Name:
Date of  Birth: (Month/Day/Year)		Your Age:
Passport #		Your Gender:	Please, select Male Female
Permanent Address
City
State/Province		Country
Postal Code:		Telephone number:
Fax:		Email:
In Case of Emergency, Please Notify:
Name:		Telephone number:
Email:
For Agent Use Only: Optional, leave blank if you're a student.
Name of Agency:		Agent Name:
Telephone number:		Country:
Fax:		Email:
Arrival Information:
Date of Arrival:		Arrival Time:
Flight Number:		Airline:
Airport:		Do you need airport pick up?	select one Yes No ($100  Extra fee)
Accommodations Requested:
Please, select "Homestay" Private Room with 14 meals per week "Home Share" Private Room without meals
Requested  check-IN  date		Check-out date
Name of School you will be attending		or Address of Internship:
Are children in the home acceptable?	Select Yes No	Are animals in the home acceptable?	Yes No   **Please note: Many Hosts have at least one animal in their home.
Personal Information:
Your English ability is	Please, select Excellent Good Fair Poor
Other Languages you speak:		Will you have a car in the US?	Select Yes No
List any hobbies and/or interests		Major of study
Do you have any allergies or medical concerns?	Please, select No Yes	If yes, please list:
Do you take any medication?	Please, select No Yes	If yes, please list:
Are you in good health?	Please, select No Yes	Do you smoke cigarettes?	Select No Yes (Please note: There is a no smoking policy for all homestays)
If you do smoke, do you agree not to smoke in or around your Host's home?	Please, select No Yes
Describe your family life including information about your parents and siblings: (Required information)
Have you traveled to the US before? Where have you traveled in the world? Please tell us about your experience.
I have read,  understand and ACCEPT the IHPS Housing Agreement [pdf].	Select No Yes (please print a copy for your records)	I have read, understand and ACCEPT  IHPS Policy on "Cancellation" and "Termination"	Select No Yes
Today's Date:		Electronic Signature:
Parent/Guardian Signature if applicant is under the age of 18 years of age:
Today's Date:		Signature:
Image Verification * :		*Please enter what you see in this box below.