STUDENT APPLICATION FORM

About You

First name	Last name
Date of birth	Place
Address
City
State
Zip Code
Country	Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia, FYR Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay USA Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands West Bank & Gaza Yemen Zambia Zimbabwe
Home tel
Vacation Home Adr.
Vacation Home tel.
Gender	Female        Male
Age
E-mail
Which Location would you like to participate	Orlando Los Angeles Washington DC Lanslebourg (France)
Date of Arrival
Date of Departure
Arrival,airline and Flight Number
Departure, airline and flight number
Name of the airport
About Your Family

Father full name
Occupation
Home Tel.
Business Tel.
Mobile Tel.
E-mail

Mother full name
Occupation
Home Tel.
Business Tel.
Mobile Tel.
E-mail

Number of sisters and ages
Number of brothers and ages
Educational Status
Name of School
Grade
1st studied Language	# years of study

2nd studied language

# years of study

Medical Information

Vaccinations	Tuberculosis Tetanus Measles Polio
ALLERGIES If yes please explain.
Are you on medication?
Blood type
Smoker	Yes   No

Hobbies and sports
Do you play any instrument?
Please list the countries you visited
Favorite food
Favorite subject at school

For Parents

HERE, PLEASE TELL US SPECIAL INFORMATION ABOUT YOUR CHILD THAT YOU WOULD LIKE US TO KNOW.

MEDICAL AUTORIZATION We, the students’ parents, hereby grant the group leader, host family and program organizer, all necessary permission and authorizations to act as legal guardians and in any situation, especially in emergencies whether medical or other, including medical treatment.                   I Accept            I do not accept

ONLY FOR HOMESTAY PROGRAMS Please write a letter to the host family. This is the very important part of your application. Here, you will have the opportunity to reveal your true personality. Do not waste this space repeating information you have provided elsewhere in this application. Please do not write less than 300 words.

You need to know that in the States, it’s is UNLAWFUL for minors to smoke, to be in possession, to buy or to sell cigarettes, and be fined minimum $100 or community work sentence and even prison. IT IS YOUR RESPONSIBILITY TO UNDERSTAND AND CONFORM TO THIS LAW. No students will be allowed to smoke in the States. FAMILIES WILL NOT ACCEPT SMOKERS. IF STUDENT SMOKES, FAMILY WILL TERMINATE HIS STAY. It is also forbidden to smoke all indoor areas.

In Virginia, California and Florida, it is illegal for under 21-year-olds to possess or consume alcoholic beverages. IT IS YOUR RESPONSIBILITY TO MAKE SURE YOU UNDERSTAND AND CONFORM TO THIS LAW. ANY STUDENT WHOSE CONDUCT IS SERIOUSLY UNACCEPTABLE OR DETRIMENTAL TO THE PROGRAM OR THE HOST COMMUNITY WILL BE DISMISSED FROM THE PROGRAM AND RETURNED TO HIS/HER NATIVE COUNTRY AT NATURAL PARENTS’ EXPENSES AFTER CONSULTATION.