Contact Details

Full Name:
Preferred name:

Sex: Male Female

Date of birth (day/month/year):
Passport number: Country of issue:

Permanent Mailing address:

Phone:

E-mail (school):

E-mail (permanent):

Background Details

Spanish proficiency level: Beginner Intermediate Advanced

Ethnic background (optional):
Religion (optional):
Field of study or profession:

Interests/sports/hobbies:

International travel experience (country, year):

Describe your personality (e.g., introvert, extrovert, talkative, quiet, temperamental, independent, etc):

Arrival, Departure & Program Details

Indicate the dates you plan to stay with a host family in Cuenca by ticking the Program to which you are applying, OR tick Other and write in your tentative homestay dates.

Intersession (Luther College)
Intersession (St. Ambrose)
Intersession (Salisbury)
Blair Summer School in Ecuador
Spring Semester in the Andes
Fall Semester in the Andes
Intersession
Summer TEFL Program
Other
(if other, specify dates:
Arrival
Departure )

Preferences, Expectations & Health

Special dietary requirements (e.g., vegetarian, salt-free, etc.):

Do you like pets? Yes No

Do you smoke? Yes No
Do you mind living with a family that smokes? Yes No

Do you mind the presence of small children? Yes No

Do you have any special habits or customs that are part of your daily routine that you feel your host family should know about? Any strong pet peeves, likes/dislikes, etc, that your host family should know about? (Please be candid.)

What do you imagine when you picture your host family? (For example: Do you imagine a big or a small house? A lot of host siblings? Are they younger or older? Do they share similar interests?)

In most cases, students are expected to walk at least 20-30 minutes to and from CEDEI. Is there a physical reason that you are unable to walk that distance? Yes No
If yes, please explain:

Why do you wish to participate in a homestay?