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Homestay Application
| Surname |
First Name |
Female |
Male |
| Country |
Language |
Date of Birth |
| Phone |
Fax |
E-mail |
| Address |
| Emergency Contact Info |
| I will be attending a |
School |
Company |
Name of School/Company |
| Length of stay in homestay |
I will rent a car Yes |
No |
| Current Occupation |
|
| Hobbies and Activities |
|
| Allergies or Foods I cannot Eat |
|
| I will accept children under the age of 6 |
Yes |
No |
| Smoke? |
Yes |
No |
| Date and Time of Arrival in Homestay |
|
| Method of Payment |
Wire Transfer |
Money Order |
| Release of Liability |
|
I am responsible for my own medical
insurance and transportation fees. I, the undersigned, accepts
responsibility
for my own behavior. The undersigned accepts responsibility
to the greatest extent permissible under the
United States law for any injury, damage, or loss, the undersigned
causes in the homestay or traveling to and
from the homestay. The undersigned agrees to release, defend, and
hold harmless, Educational Services, Intl. and ESI
host families from any claim or liability for any such damage, injury,
or loss. |
| Signature of Applicant |
| Date |
| Signature of Parent or Guardian (If
applicant is under 21) |
|
