What term do you want a homestay family?

Term:

Contact Information

Family Name:

*

First Name:

*

Middle Name:

*

Present Address:

*

City:

*

State or Province:

*

Country:

*

Postal Code:

*

Phone number:

*

FAX number:

*

Birth date:

Month 01 02 03 04 05 06 07 08 09 10 11 12   Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925

Birth Place:

Nationality:

Sex:

Male   Female

Email Address:

Permanent Address:

*

City:

State or Province:

Country:

Postal Code:

Phone number:

My Family

Personal Information

Would you feel comfortable living with a family with small Children?

Yes   No

Is Religion an important part of your life?

Yes   No

Are you a member of a club or organization?

Yes   No

What countries have you visited?

Personal Habits

Do you smoke?

Yes   No   Sometimes

Do you drink alcoholic beverages?

Yes   No   Sometimes

Do you have specific chores to do at home?

Yes   No   Sometimes

If yes (or sometimes), do your chores include...

Personal Health

Condition of your health:

What can you say about the condition of your health?

Do you take any medication regularly?

Yes   No
If YES, why do you take medicine?

Are you allergic to any animals?

Yes   No
If YES, what kind of animals?

Are you allergic to any plants?

Yes   No
If YES, what kind of plants?

Are you allergic to any food?

Yes   No
If YES, what kind of food?

Are you allergic to any medicine?

Yes   No
If YES, what kind of medicine?

Activities

How do you spend your free time?

Reading

Often   Sometimes   Never

Playing Sports

Often   Sometimes   Never
Which sports?

Watching movies

Often   Sometimes   Never

Watching television

Often   Sometimes   Never

Listening to music

Often   Sometimes   Never
What kinds of music?

Playing a musical instrument

Often   Sometimes   Never
What kinds?

Shopping

Often   Sometimes   Never

Siteseeing

Often   Sometimes   Never

Cycling

Often   Sometimes   Never

Hiking

Often   Sometimes   Never

Talking with friends

Often   Sometimes   Never

Other interests and hobbies:

School

What is your English speaking ability?

Good   Fair   Poor   Very Poor

How many years have you studied English?

Last school attended:

Major:

Present or future occupation:

Personality Information

Please describe yourself using the following information. Are you...

Adaptable

Often   Sometimes   Never

Independent

Often   Sometimes   Never

Serious

Often   Sometimes   Never

Shy

Often   Sometimes   Never

Open-Minded

Often   Sometimes   Never

Is there any other information that you think is important for your host family to know?

Type other important information here.

Application Fee

How would you like to pay the application fee?

Due: 150 US Dollars
Credit Card Check Money Order (Click to change.)

Please send payment (check, international money order or credit card number) with Part 2 of the homestay application via air mail to:

American English Institute
5212 University of Oregon
Eugene, OR 97403-5212

Submit Homestay Application

Submitting Form:

Click button to submit application:

After you submit Part 1, Part 2 of the Homestay application will appear. Print out Part 2, sign it and send to AEI by air mail.