| Surname |
First Name |
| Country
|
Native
Language |
| Date of Birth
|
Age
|
| Gender
|
Phone
|
| Fax
|
E-mail
|
| Address
|
| In
case of an emergency, contact |
| I
will be attending a Name of School or Company |
| How
long will you stay in your homestay? |
| I
will rent a car 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 |
| Smoke?
(No smoking is allowed in the homestay) |
| Date
and time of arrival in homestay? |
| I
will pay by (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: |
|
Thank you! See you soon! |
