*First Adult FULL Name:
       Relationship:

*Second Adult FULL Name:
       Relationship:

*Present Address:

*City    *State:    *Zip:

*Phone:    E-mail:

Mobile Phone 1:    Mobile Phone 2:

*First Adult's Occupation:

*Second Adult's Occupation:

*First Adult's Birthdate:    

*Second Adult's Birthdate:

Please list all children living at home, and any other persons or family members living in the household:

*Each student requires a private bedroom

*Will student be sharing a bathroom? Yes No  No Answer
      If yes, with whom?

*How long would you be able to host a student?

*Would the student's bedroom have a desk (or table)? Yes No No Answer

*Do you have internet access for a student? Yes No  No Answer
      If yes, what kind?

*Any other comments on accommodations / facilities?

*Will you permit smoking? Yes Outside Only No No Answer

*Will you permit alcohol in your home? Yes No No Answer

*If your family has pets, please specify type and number:

*Preferences regarding student:   Male Female No Preference

*What transportation options (please specify if it is a bus line):

*How long would it take a student to reach the nearest school by public transportation?

*What time do you usually go to bed and get up?

*International travel experience?

*Foreign languages spoken, if any:

*What is your family's religion?

*How did you hear about our homestay program?

*Please give the name and phone numbers of 3 local references:
1 .Name: Phone:
       Relationship:

2. Name: Phone:
       Relationship:

3. Name: Phone:
       Relationship:

*This section is the most important to make a pleasant homestay for both your family and the student. Please tell us why you want to be a host family for an international student, and any comments regarding family interests or hobbies or any other information that will help us to introduce you and your family to a prospective student.

We (OvECS) will make every effort to match a student with your family. However we can not guarantee a perfect match or placement.

By typing your name into the box below, you attest that all the information above is true and accurate to the best of your knowledge. You also acknowledge that you are electronically signing this application and authorize OvECS to process and research all information provided.

*Signature:

First Name:

Last Name:

Date of Birth: Age: Gender:

Nationality:

Name of University: Major:

Phone:

Mobile Phone: