8 Stimson Avenue, Providence, RI 02906 (401)421-7181 Date: _____________

Last Name:______________________ First Name(s):_________________________

Address:_______________________________________Tel:__________________

City:___________________________ State:____________ Zip:_______________

Date available:___________________ Email Address:__________________________

ABOUT YOU: ( ) Single

( ) Married; ages of children living at home:_________________________

Occupation(s):_______________________________________________________

Languages spoken:_____________________________________________________

Areas of special interest (sports, music, hobbies, etc.): __________________________

_________________________________________________________________

Previous international experience (travel, work, etc.) :__________________________

_________________________________________________________________

ABOUT YOUR STUDENT: Do you wish to be matched with: ( ) One ( ) Two ( ) A Family?

Do you prefer to be matched with ( ) male ( ) female internationals?

Are you interested in:

a. students from a particular part of the world?_______________________________

b. students in a particular field of study? ___________________________________

Would you be willing to host a student from another country or field of study? __________

Would you prefer being called before match is made? __Yes __No

Is there anything else we should know? ______________________________________