HAWAII HOMESTAY APPLICATION FORM
(Print out this form and send with your deposit)

Name		Sex	Age
Home Country	Email address
Address
Telephone	Fax
Place of birth	Date of birth
Father's or Husband's name	Profession
Mother's or Wife's name	Profession
Brothers and Sisters	Ages
Address and Telephone

PROGRAM DESIRED:

	Group	Person I would like to room with
	Individual	School attending in Hawaii

Do you like children?		Number of years English study
Do you like pets?		Your future/present profession
Do you smoke?		Your interests and hobbies
Do you have allergies or require special medical treatment? If yes, please explain:
Name of your medical insurance company

Dates requested for Homestay: From ______________ to _____________

Please include with this application:

1. Letter of introduction for host family
2. Letter explaining why you want to be in the Homestay program and what your goals and educational plans are (individual applicants only)
3. Signed Rules and Agreement form
4. Photograph
5. Non-refundable registration fee -- Please contact us via email to determine your registration fee.

In applying to be a participant in the Hawaii Homestay program I agree to have a valid passport, visa and medical insurance. I further agree that Hawaii Homestay staff and families are not responsible for my health and safety and I will pay any expenses incurred by them in taking action necessary in the interest of my health and safety. I accept the twelve rules for Homestay participants.

Signature of Applicant __________________________________________ Date ___________________

Signature of parent if student under 18 _____________________________ Date ___________________