Online Homestay Application

Starting Quarter

Fall Winter Spring Summer

Year

Approximate Arrival Date

Choose a date or type in with format MM/DD/YYYY. If you are not sure yet, please let us know at least one week in advance.

Flight Info

School

School - Other

Prefix

Mr. Ms. Mrs.

First Name

Middle Initial

Last Name

Nickname

Sex

Male Female

Student's Parent's / Guardian's Address

Student Birthday

Choose a date or type in with format MM/DD/YYYY

Student Age

Student Nationality

Student Native Language

Email Address

(Mobile) Phone Number

Please input only numbers (ex 123456789)

Do you plan to bring your phone to the US?

Yes No

Social Media ID/Name

Such as FACEBOOK, LINE, KAKAOTALK, WECHAT, SKYPE, WhatsApp, etc. Will be used mainly to keep in contact with USAI staff and will be kept confidential.

Are you applying through an agency?

Yes No

Agency Name

Agency Address

Agency Country

Contact Person

Agency Phone

Agency Email

Student Family Members (Name, Relationship, Age, Occupation) - 1

Student Family Members (Name, Relationship, Age, Occupation) - 2

Student Family Members (Name, Relationship, Age, Occupation) - 3

Student Family Members (Name, Relationship, Age, Occupation) - 4

Student Family Members (Name, Relationship, Age, Occupation) - 5

Student Family Members (Name, Relationship, Age, Occupation) - 6

Do you have any mental, medical, physical requirements or special needs?

Yes No

If yes, please explain your requirements:

Are you taking any medicine?

Yes No

If yes, please explain your medicine:

Do you have any allergies?

Food Animals Medicine Other None

If yes, please explain your allergies:

Do you prefer families with children?

Yes No No Preferece

If no, please indicate age range:

Do you prefer families with pets?

Yes No No Preference

If no, please indicate which pet(s):

Interaction with Host Family

A lot of interaction Moderate interaction Minimal interaciton

Do you smoke?

Please answer honestly. This is for placement purposes only.

Yes No

Do you plan to buy a car in the US?

Yes No

Please rate your English level

I only know a few words and basic phrases Beginner - can understand if spoken slowly Intermediate - simple conversations Advanced - complicated conversations Fluent - speaking, reading and writing fluently

Are you:

Shy Independent Social Outgoing Open-minded Talkative Quiet

How would you describe yourself?

What are your favorite foods?

What foods do you not like?

What are your hobbies and interests?

Reading Writing Drawing Cooking Music Art Sports Movies Walking Exercise Hiking Camping Video/Computer games Other

If other, please describe:

A Letter to Your Host Family:

How long do you plan to stay in the USA?

How long do you plan to stay with your host family?

Previous travel abroad:

Do you have any friends or relatives in the U.S. or Canada?

Yes No

If yes, please give their name, relationship to you, phone number, and address:

How did you hear about USA International?

School Internet Other (please write other in text box)

Other

Contact Info While in U.S. - Email Address

Contact Info While in U.S. - Mobile Phone Number

Please input only numbers (ex 123456789)

Do you need Airport Pickup Service?

Yes No

Arrival Date at Seattle-Tacoma International Airport

Leave blank if undecided

Time of Arrival

Airline

Flight Number

From

Please upload a photo of yourself (Alphanumeric filenames with 2MB Limit)

Payment Method

Paypal (Visa & Mastercard) Check/Money Order Bank Wire Transfer Other

Do you agree to USAI Homestay guidelines?

Yes No

USA インターナショナル

Cultural & Social Development / International Students' Housing Coordination

Online Application

Hold Harmless Agreement