Student information

Please type or print legibly in black ink, so that these forms can be photocopied.

Answer all questions. Please complete this application as honestly as possible.

YFU will use this information to select your host family.

---------------------------------------STUDENT INFORMATION----------------------------

Legal Name (as it appears on your passport) Address

Last Name:__________________________________ Address: ____________________________

First Name:__________________________________ City/Town:___________________________

Middle Name: _______________________________ State/Province: ____________­­­­­­­­­­­­­­­­­­­___________

Nickname: __________________________________ Zip Code/Postal Code:__________________

Sex: Male Female Telephone: (____________) ____________

Area/City Code

Home Fax: (____________) ___________

Area/City Code

Date of Birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec________________

Month (circle one) Day Year

Place of birth:_______________________________________________________________________

City/Town State/Province Country

Country of Citizenship:____________________ Country of Permanent Residence:_______________

--------------------------------------------------FAMILY INFORMATION--------------------------------------

Ilive with (check all that apply): Mother Father Stepfather Stepmother Guardian:___

Other, please specify:___________________________________

My brother’s name(s) and age(s):_______________________________________________________

My sister’s name(s) and age(s): ________________________________________________________

My father’s name (or male guardian): ___________________________________________________

Last Name First Name

Address (if different from yours): ____________________________________________________

Occupation:______________________________________________________________________

Employer: _______________________________________________________________________

Business Telephone: (_________) _____________ Business Fax Number: (_________) ________

Area/City Code Area/City Code

My mother’s name (or female guardian): _________________________________________________

Last Name First Name

Address (if different from yours): ____________________________________________________

Occupation: _____________________________________________________________________

Employer: _______________________________________________________________________

Business Telephone: (_________) _____________ Business Fax Number: (_________) ________

Area/City Code Area/City Code

-------------------------------------------------OFFICE USE ONLY-----------------------------------------------

Year Country Program Std. No. Sponsor Code Gateway City To Country

_ _ _ _ _ _

Tracking Code

RUS -- REG, FSA-SEM