1. Personal Information

I am a (n)
First Name: Last Name:
Date of  Birth: Your Age:
Passport # Your Gender:
Permanent Address
State/Province Country
Postal Code: Telephone number:
Email: Confirm Email:

In Case of Emergency, Please Notify:

Name: Telephone number:

2. Agent Details

(Optional, leave blank if you’re a student)
Name of Agency: Agent Name:
Telephone number: Country:
Fax: Email:

3. Arrival Information

Date of Arrival: Arrival Time:
Flight Number: Airline:
Airport: Do you need airport pick up? ($125  Extra fee-Most Airports)

4. Accommodation Details

Type of accommodation requested:

Requested  check-IN  date Check-out date
Name of School you will be attending or Address of Internship:
Are children in the home acceptable? Are animals in the home acceptable?
**Please note: Many Hosts have at least one animal in their home.

5. Personal Details

Your English ability is
Other Languages you speak: Will you have a car in the US?
List any hobbies and/or interests Major of study
Do you have any allergies or medical concerns? If yes, please list:
Do you take any medication? If yes, please list:
Are you in good health? Do you smoke cigarettes? (Please note: There is a no smoking policy for all homestays)
If you do smoke, do you agree not to smoke in or around your Host’s home?
Describe your family life including information about your parents and siblings: (Required information)
Have you traveled to the US before? Where have you traveled in the world? Please tell us about your experience.

5. Undertaking

I have read,  understand and ACCEPT the IHPS Housing Agreement [pdf]. (please print a copy for your records)
I have read, understand and ACCEPT nbsp;IHPS Policy on “Cancellation” and “Termination”
Today’s Date: Electronic Signature:

Parent/Guardian Signature if applicant is under the age of 18 years of age:

Today’s Date: Signature: