Professional Documents
Culture Documents
Host Family Form
Host Family Form
This information will be kept confidential and will not be shared with other program participants
o I do not want to observe a religion while in the United States (go to question 18)
o I want to practice my religion in the United States (choose one option below)
o I am curious to see religious services of my faith in the United States
o I would like the opportunity to pray or attend services of my religion regularly
It is very important to me to have the opportunity to pray or attend services regularly
17 Please specify which religious services you would like to attend:
I’m a Protestant Christian . My church is The Nusantara Evangelical Reformed Church ( GPIN )
If your host family attends religious services, they will invite you to join
Yes
18 them. This would be a good cultural exchange opportunity. Are you No
interested in doing this if the opportunity arises?
19 Yes No
Do you have any allergies?
1. Dust
If you have allergies, what are you allergic to? 2. -
20
(For example: pollen, shellfish, peanuts, cats, dust)
3. -
Allergy Treatment
Please list any treatment for allergies, if 1. Dust Using mask
21 applicable (please use additional space if
needed). 2. -
No Goat’s meat
List your dietary restrictions or preferences, if
any. (For example: vegetarian, no pork, kosher, No cat’s meat
22
halal, no shellfish.) We will try our best to
accommodate you.
-
Do you have any physical limitations we should
23 be aware of (example: hard of hearing)? Please
list any.
-
Do you have any medical conditions we should
24 know about (example: Diabetes, Asthma)?
Please list them, plus any relevant information.
1. -
2. -
Please list any medications you take and
25 3. -
dosages (please use additional space if needed)
4. -
5. -
Do you use social networking sites such as Yes No
26
Facebook or Twitter?
Yes No
28 Do you have access to high speed internet?
If yes, where (example: at home, at an internet
29 At home
café, at school)?