Applicant Information (Required) School Name: Please select the beginning quarter: Spring Summer Fall Winter Year: (YYYY) How long do you plan to stay with your host family? Name: Gender: Male Female Mailing Address: City: State (Prefecture): Zip (Postal) Code: Country: Phone: Fax: E-mail: Age: Nationality: Passport#: Family Information 1. Name:   Age:   Relation:   Occupation:   Living with you?: Yes No       2. Name:   Age:   Relation:   Occupation:   Living with you?: Yes No       3. Name:   Age:   Relation:   Occupation:   Living with you?: Yes No       4. Name:   Age:   Relation:   Occupation:   Living with you?: Yes No       5. Name:   Age:   Relation:   Occupation:   Living with you?: Yes No Emergency Contact (Required) Name: Relationship to you: Address: Phone: Fax: E-mail: Educational Background Last School attended: Major Course of Study: Period of Study: From: To: (MM/YYYY) Working Experience 1. Company Name:   Position::   Period of Employment: From: To: (MM/YYYY)       2. Company Name:   Position::   Period of Employment: From: To: (MM/YYYY)       3. Company Name:   Position::   Period of Employment: From: To: (MM/YYYY)       4. Company Name:   Position::   Period of Employment: From: To: (MM/YYYY) Information for Homestay Placement Transportation (Required) How do you plan to go to school? I plan to buy a car I plan to commute by bus Do you have or plan to obtain the International Driver's License? Yes No Do you plan to obtain Washington State Driver's License? Yes No Food (Required) What kind of food do you like? What kind of food do you dislike? Are you are vegetarian, or do you have any diet restrictions? Are you allergic to any food? Yes No If yes, please explain. Children & Pets (Required) Do you like children? Yes No Do you like animals? Yes No Are you allergic to any animal? Yes No Hobbies and Interests (Required) What are your hobbies? Do you like sports? Yes No Experience Away from Home (Required) Have you traveled to a foreign country before? Yes No If yes, please explain where you went and for how long you were there. How long do you plan to study in the USA? Additional Questions (Required) Please select the word(s) that best describe you: Shy Independent Adventurous Quiet Sociable Outgoing Talkative Patient Serious Funny Dependent What would you like to experience with your host and learn from the homestay program? What are your future goals and career interests? Is there anything you feel is important that ICC knows before placing you in a homestay? Please write a short note to your future host. Student Health Information(Required) Date of birth: (MM/DD/YYYY) Blood Type: Select "yes" if you have any of the following, then provide details. Allergies and/or Drug Reactions No Yes Chronic Illness No Yes Regular Medications No Yes Tetanus Immunization No Yes If "yes," please provide the date of immunization. (MM/YYYY) Payment Information (Required) Payment amount: $ (USD) Payment Method: Wire Transfer Money Order/Personal Check * Instruction for wire transfer, money order and personal check will be sent at a later date.