Homestay Application

Surname	First Name
Country	Native Language
Date of Birth	Age
Gender Male Female	Phone
Fax	E-mail
Address
In case of an emergency, contact
I will be attending a School Company None Name of School or Company
How long will you stay in your homestay?
I will rent a car No Yes   My occupation is
Favorite Hobbies and Activities
Allergies or Foods I cannot eat
I will  accept a Host with Children under the age of 6  Yes No
Smoke? No Yes (No smoking is allowed in the homestay)
Date and time of arrival in homestay?
I will pay by  Wire Transfer Money Order (For money orders, make payment to: Educational Services, Intl. You will receive your homestay information after our office receives your payment)
Medical Insurance Info
Release of Liability: I , the individual applying for a homestay, agree to the following:  I am  responsible for my own medical insurance and transportation fees.  I am responsible for my own behavior.  I am responsible to the greatest extent permissible under the United States law for any injury, damage, or loss, which I may cause in the homestay or traveling to and from the homestay.  I agree to release, defend and hold harmless, Educational Services, Intl and EST host families from any claim or liability for any such damage, injury, or loss. I have read the above Release of Liability statement:  No Yes
Thank you!  See you soon!