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Enrollment Form

Personal Information
Complete Name (required)
 Email (required)
 Nationality
Birthday (MM/DD/YY)
 Sex
 Male Female		 Profession
Steet Address
 Zip Code
 State

City
 Country
 Telephone - Home -
Fax
 Telephone - Work -
 Passport Number
Ethnic Origin
Arrival Details
Airport Pickup
 Yes No 		Arrival date (MM/DD/YY)
 Time (HH:MM)
Airline
 Flight
 Contact in case of emergency
Medical Concerns
 Yes No 		Add Info
Host Family Information - Do you mind if the host family has:
Smokers?
 Yes No 		Children?
 Yes No No pref. 		Pets?
 Yes No No pref.
Another student?
 Yes No No Pref.		 Are you a smoker?
 Yes No 		Hobbies / interests?
Additional Comments

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