Student Name:      Date of Birth:  

Mother's Name:      Father's Name:     

Physical Home Address:      City:  

Country of Residence:  

Country of Citizenship:  

E-mail:     Telephone:

Do you have a potential family willing to host you in the United States?   Yes  No

Are you related to this family?   Yes  No

If yes, please provide name, address, including city, state and zip code, phone number and email address:

What things would you like to do while one program ie sports, music, drama, theater, etc?

Type the code below. Please no spaces.

NU0L8FBI