NAMEDATE OF BIRTHAGE　

　SEX:MALEFEMALE 　OCCUPATION

　NUMBER&STREET

　CITYPREFECTURE

　DAYS REQUESTED FOR HOMESTAY

　TELEPHONE:FAX:

　FATHER'S NAMEPROFESSION

　MOTHER'S NAMEPROFESSION

　OVERSEAS TRAVEL ACCIDENT INSURANCE

　COMMENTS:

  DO YOU SMOKE?    YESNO
  DO YOU LIKE CHILDREN? YESNO
  DO YOU LIKE PETS?    YESNO　
  ARE YOU ON ANY MEDICATION? YESNO　IF YES EXPLAIN 

　E-MAIL ADDRESS