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Student Homestay Online Application Form


Please fill out the form and click "Preview Application". You can also download the form in pdf. 


USA International, Inc.
9614 NE 201st Street Bothell, WA 98011 USA
Phone: (425)-483-5974 Fax: (425)-485-1891 E-mail: info@ushomestay.com
 
* Required Field.
Quarter * Year *
Fall Winter Spring Summer YYYY
Arrival Information
Approximate arrival date * Flight Info
School *
Other
Student Name *
Mr. Mrs. Ms. First
Middle
Last
English Name/Nickname
Sex *
Male Female
Are you applying through an Agency? * When selecting yes, all fields are required.
Yes No
Agency Name Contact Person
Agency Address
Agency Country Agency Fax
Agency Phone Agency Email
Student Mailing Address * Student Permanent Address *
Same as Mailing Address
Address 1
Address 2
City
State/
Prefecture
Zip code
Country
Phone
FAX
E-mail
Address 1
Address 2
City
State/
Prefecture
Zip code
Country
Phone
FAX
E-mail

Birthday * Age *
MM/DD/YY
Nationality * Native Language *
Family Members

  Name Relationship Age Occupation
1
2
3
4
5
6

Questionnaire *
Do you have any mental, medical, physical requirements or special needs? Yes No
If yes, please explain:
Are you taking any medicine? Yes No
If yes, please explain:
Do you have allergies?       Food No Yes
Animals No Yes
Medical No Yes
Other No Yes
Do you smoke? Yes No
Most host family homes are non-smoking. If you do smoke, you will be required to smoke outside.
Do you prefer children? Yes No No Preference
If no, please indicate range of age:
Do you prefer pets? Yes No No Preference
If no, please indicate which one(dog, cat, other):
How long do you plan to stay in USA?
How long do you plan to stay with Host family?
Previous Travel abroad:
Do you have any friends or relatives living in the U.S. or Canada?
Yes No
Name Relation Phone Address
How did you hear about USA International?
School   Internet   Other  

Letter of Self Introduction *
In the space below, please introduce yourself. Please write about yourself, any special interest, such as sports or hobbies you may have. Remember to attach a recent photo of yourself and possibly a photo of your family, home, or pets.

A Letter to Your Host Family.


What is your personality (shy/independent/social/outgoing/open-minded/talkative) and what is your level of English?


What are your hobbies and interest? What are your future goals/plans/career interests?

What can you share with your host family about your culture?


What is your expectation or priority with the host family? (Would you like lots of interaction, spend time with family or do you want to be independent with moderate interaction?)

Airport Pick-up
Do you need airport pickup service? *
Yes No

Contact info while in U.S.
E-mail Address
Mobile Phone

Arrival Date at Seattle-Tacoma International Airport
Time of Arrival
a.m. p.m.
Airline
Flight Number
From
Please upload a photo of yourself.

Total size of attachments should be less than or equal to 5,000 KB.


( You can attach any types of files except those which are exe, com, js, scr types.)
Description
(e.g. the color of the clothes you'll be wearing, if oyu wear glasses, if you have long/short hair, etc...anything that helps us find you at the airport!)
  • Airport pick-up by USAI or host family is available for a service fee of $125.00 per person Monday - Sunday, 8:00 AM - 8:00 PM Pacific Standard Time in the U.S.
  • Airport pick-up is limited on U.S. Holidays
  • Flight information must be received at least 2 weeks before arrival date. You will be on our waiting list if it is less than 2 weeks.

Note: The placement service fee is non-refundable, damage deposit is refundable with notice and no damage, Airport pick up service is refundable with a 7 day cancel notice.

Methods of Payment *
Credit Card (agree to be charged the fees on the credit card which information is provided below.)

Visa   Master Card
Name on Credit Card
Card Number Exp.Date
MM/YY
Last 3 digits on signature panel located on the back of the card.  
Personal Check / Money Order (I will mail the fees to the office of USA International, Inc. Please note payment must be received before application is processed.)
Other 

HOLD HARMLESS AGREEMENT

USA International reserves the right to use its own discretion when accepting prospective students. Applications that contain erroneous or false information are subject to annulment. USA International and its agents will be held harmless from and against all claims, damages, actions, liability, and expense concerning loss of life, or personal property arising from a student participating in housing programs.

* I agree with HOLD HARMLESS AGREEMENT and "Student Homestay Guidelines."