Read Instructions Before Completing

Application Date (required) :

Name of UC Davis program I will be attending (required):

Name of my current University (required):

Personal Information

Student’s Last Name(required)
First Name (required)
(in Western Characters)

Birth Date (required) Age (required)
Gender (required) M F

Home Address (required)

City: (required)
State/Province

Zip Code
Country(required)

Email (required) Telephone
Fax

Student’s Nationality
Occupation other than “Student”

Height in Centimeters (Required for bicycle rental)

Homestay Program

Choose one:  Homestay Program Homestay PLUS Program Apartment

Which meal option are you interested in? (Does not apply for apartments)  No Meal ($20/night) Up to Three Meals ($27/night) Host Family PLUS Program ($30/Night)

Travel Information

Expected Arrival Date in Davis

Expected Departure Date from Davis Airlines

Arrival Airport
Transportation from airport  Bus Train Shuttle Undetermined

Family Information

Father’s Information

Name Email
Phone Occupation
Level of Education

Mother’s Information

Name Email
Phone Occupation
Level of Education

Brothers & Sisters

Sibling’s Name  Brother Sister     Age

Sibling’s Name  Brother Sister     Age

Sibling’s Name  Brother Sister     Age

Emergency Contact Information

Name of person to contact
Relationship to Student

Telephone Fax
Email

Complete Address

Health Information

Are you taking any medication?  Yes No    
If yes, please list the medication and its purpose

Do you have any physical limitations?  Yes No    
If yes, please describe

Do you have allergies?  Yes No If yes, please describe:

Do you have specific allergies related to pets?  Yes No

If yes, please indicate what type of pet(s) you are allergic to

Would you consider a host family with pets?  Yes No

The following information will be used to help identify the best possible housing option.

English ability  Beginner Intermediate Advanced

Is this your first time to visit the United States?  Yes No     If no, when did you last visit?

Have you visited other countries?  Yes No     If yes, please list

Are you a smoker?  Yes No    
If yes, are you willing to smoke outside ONLY?  Yes No

Are there any foods you are not able to eat?  Yes No    
If yes, please list

Do you like to cook?  Yes No    
Are you interested in helping prepare the evening meal?  Yes No No Preference

Are you interested in learning how to cook?  Yes No No Preference

Would you prefer a home with children under 6 years of age?  Yes No No Preference

Would you prefer a home with children between 6 and 14 years of age?  Yes No No Preference

Would you prefer a home with no children?  Yes No No Preference

What are some of your favorite hobbies and activities?

Please describe your personality: Check all that are appropriate

 Talkative Open­minded Messy Calm Frugal Active Serious

 Quiet Noisy Cheerful Outgoing Athletic Shy Picky Eater

 Nervous Helpful Energetic Polite Respectful Private Religious

 Thoughtful Organized Cautious Funny Engaging Tidy

In addition to your educational goals, what else would you like to achieve or experience during your stay in the United States?

What degree of interaction do you prefer with your host family? One that encourages more time with the family  Yes No

One that will allow you more independence/freedom  Yes No No Preference

Many American families are open to diversity including religion/spirituality, sexual orientation, and gender identity. If you believe that how you identify in any of these areas may compromise your home stay experience please specify your need. The information shared in this question will only be shared with your host family if necessary.

Please share any additional information that you think would be important for us to know. It is our goal to make your experience positive and rewarding.

Other things you would like your host family to know about you

Name of person who referred you to Student GPS?

Enter Verification Code: