UI Host Family Program - Universitas Indonesia Form for students
Student Application Form
Host Family Program
PERSONAL INFORMATION
Ms
Mr
Name: ...................................................................................................
Place, Date of Birth: ............................................................(dd/mm/yy)
Nationality:.............................................................................................
Address (in home country): ...................................................................
...............................................................................................................
Phone/Fax: .............................................................................................
Mobile Ph................................................................................................
E-mail address: ......................................................................................
In case of emergency, please contact (name, address, phone):............
...............................................................................................................
...............................................................................................................
...............................................................................................................
Arrival date (flight no./arrival date & time):............................................
Departure date (flight no./arrival date & time):......................................
ADDITIONAL INFORMATION
Have you ever been to Indonesia?
Yes
No
Do you speak Indonesian Language?
Yes
No
If yes, please indicate ............................................................................
Beginner
Intermediate
Advanced
What is your native language?...............................................................
What other foreign language(s) do you speak?......................................
Have you already stayed in a Host Family?
Yes
No
Do you mind being in a Host Family with pet(s)?
Yes
No
What pet(s) do you like and dislike?.......................................................
...............................................................................................................
Do you smoke?
Yes
No
Do you mind being in a smoking family?
Yes
No
Are you in a good health?
Yes
No
Is there anything particular we should know in order to select your host family?
(dietary restrictions, medical concerns, allergy).....................................
...............................................................................................................
...............................................................................................................
Please describe yourself by briefly writing about the following
My family
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My character
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My likes and dislikes
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My hobbies and interests
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.........................................................................................................................
List any foods you cannot eat and specify the reasons
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Please write a brief statement about what experience do you hope to have with
Host Family Program. Please consider not only what kind of host family you
would like to live in, but also how do you plan to participate in and contribute
to the crosscultural exchange (Please keep in mind that we will do our utmost
to make the best match possible but all that desires cannot always be met)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Date
___________________
Name
________________________
Signature
_____________________
Host Family Program
PERSONAL INFORMATION
Ms
Mr
Name: ...................................................................................................
Place, Date of Birth: ............................................................(dd/mm/yy)
Nationality:.............................................................................................
Address (in home country): ...................................................................
...............................................................................................................
Phone/Fax: .............................................................................................
Mobile Ph................................................................................................
E-mail address: ......................................................................................
In case of emergency, please contact (name, address, phone):............
...............................................................................................................
...............................................................................................................
...............................................................................................................
Arrival date (flight no./arrival date & time):............................................
Departure date (flight no./arrival date & time):......................................
ADDITIONAL INFORMATION
Have you ever been to Indonesia?
Yes
No
Do you speak Indonesian Language?
Yes
No
If yes, please indicate ............................................................................
Beginner
Intermediate
Advanced
What is your native language?...............................................................
What other foreign language(s) do you speak?......................................
Have you already stayed in a Host Family?
Yes
No
Do you mind being in a Host Family with pet(s)?
Yes
No
What pet(s) do you like and dislike?.......................................................
...............................................................................................................
Do you smoke?
Yes
No
Do you mind being in a smoking family?
Yes
No
Are you in a good health?
Yes
No
Is there anything particular we should know in order to select your host family?
(dietary restrictions, medical concerns, allergy).....................................
...............................................................................................................
...............................................................................................................
Please describe yourself by briefly writing about the following
My family
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My character
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My likes and dislikes
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
My hobbies and interests
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.........................................................................................................................
List any foods you cannot eat and specify the reasons
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Please write a brief statement about what experience do you hope to have with
Host Family Program. Please consider not only what kind of host family you
would like to live in, but also how do you plan to participate in and contribute
to the crosscultural exchange (Please keep in mind that we will do our utmost
to make the best match possible but all that desires cannot always be met)
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
Date
___________________
Name
________________________
Signature
_____________________