International Programs
Educational Services Building – 3rd Floor
Admissions and Advising Wing
Bellevue University
1000 Galvin Road South
Bellevue, Nebraska 68005


Homestay Application for Students
Phone: 402-557-7281
Fax: 402-557-5423
Email: international@bellevue.edu
Website: www.bellevue.edu
Click on International


Last (Family) Name:     First (Given) Name:
 
Date of Birth (Month/Day/Year):     Male   Female
 
Address:     Telephone:
 
Email:  
 
Country of Residence:     Nationality:
 
Passport Number:     Native Language:
 
Bellevue University Student ID Number (if available):
 
Level of English Language: No English   Beginner   Intermediate   Advanced
 
Have you ever been to a foreign country? Yes   No
 
      If yes, where have you traveled and for how long?
 
FAMILY INFORMATION:
 
Mother's Name:     Age:     Occupation:
 
Father's Name:     Age:     Occupation:

              Please list names of your brothers and or sisters Age                           Please list names of your brothers and or sisters Age
1.               6.
2.               7.
3.               8.
4.               9.
5.             10.

Emergency Contact:
 
Full Name:
 
Address:
 
Country:     Telephone:
 
Email:     School Start Date:
 

PERSONAL INFORMATION:
 
Current or Desired Occupation:
 
Favorite Hobbies and Interests:
 
Would you prefer small children in your host family (under 6 years old)?   Yes  No  No Preference
 
Would you prefer older children in your host family (between 6 and 18)?   Yes  No  No Preference
 
Would you be comfortable with a family that owns a dog?   Yes  No  No Preference
 
Would you be comfortable with a family that owns a cat?   Yes  No  No Preference
 
Would you be comfortable with a family that smokes?   Yes  No  No Preference
 
Do you smoke?   Yes  No
 
Do you plan to have a car during your homestay?   Yes  No
 
Do you practice religion?   Yes  No     If "yes", which one?
 
Please list any health problems, allergies, or dietary restrictions:
 
Please list any special physical or emotional conditions you have that could affect your homestay placement:
 
Please list any foods you cannot or do not like to eat:
 

Your Personality:
Please check all which describe you:
Quiet Tidy Cautious Religious Noisy
Shy Cheerful Messy Open-minded Picky eater
Outgoing Independent Frugal Organized Serious
Private Talkative Athletic Energetic Nervous
Calm Other


Please write a letter to your host family to tell them what you would like them to know about you.
  • What are your hobbies and interests (examples: movies, camping, sports, computers)?
  • Describe your hometown - is it a big city, countryside, how many people live there?
  • Describe your life with your family and friends.
  • Do you have any pets?
  • Describe your personality
  • Why do you want to live with a host family?
     

    OTHER INFORMATION:
     
    Arrival Date in Omaha:     Airline/Flight Number:
     
    Arrival Time in Omaha:
     
    How did you learn about the Homestay program?
    Another host family         Neighbor/friend         Radio         Newspaper ad         Another international student         BU Website
    Other (please specify)
     

    PROGRAM AGREEMENT:
     
    In my homestay, I agree to:
    • Treat all host family members with respect.
    • Make every effort to adapt to my new home and become part of the family.
    • Follow my host family's household rules.
    • Bring guests into my host family's home only with prior permission.
    • Not drink any alcohol, including beer and wine, if I am under 21 years old. I also understand that the use of any illegal drugs is strictly forbidden, and if I am caught using them I will be asked to leave my homestay immediately.
    • Only make long distance telephone calls at my own expense (possible ways to do this: cell phone, pre-paid telephone card, internet services, such as Skype).
    • Pay for any damages I cause to the host family's home or property.
    • Pay my homestay fees on time, directly to the host family.
     
    I have read and understood the program agreement. I agree to follow the homestay policies listed on this agreement.