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Section A. Personal & Contact Information

Last Name			First Name
Gender			Passport Number
Occupation
Name of College or University
Date of birth			Age
Marital Status
Telephone (Country Code + Area Code + Number)
Address			City
State			Country
Zip Code
E-Mail Address
Spanish Level Information

Section B. Emergency Contact Information

Name, address, and telephone number of person to contact in case of an emergency:

Name		Address (Please enter the address, city and ZipCode in one single line)

Telephone (Country Code + Area Code + Number)

Section C. Flight Information

Section D. Preferences Information

		For more details in your answer, use the text box
1.	Do you smoke?
2.	Do you like pets?
3.	Would you like a family with children?
4.	Do you have any dietary requirements?
5.	Do you suffer from any types of allergies?
6.	Do you have special interests, activities or hobbies?
7.	Do you have any physical or emotional disability we should take into consideration in choosing an appropriate host family for you?
8.	Are you traveling with a companion?
9.	If the answer to question 8 is yes, would you like you and your companion to be placed with the same host family?
10.	If not in the same house, would you like to be in the same neighborhood with your companion?
11.	If you feel there is anything else we should know in order to best place you with a compatible host family, please indicate.

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