1.	Last Name*

2.	First Name*

3.	Email Address*

4.	Gender*
	Female Male

5.	Date of Birth*
	mm/dd/yyyy

6.	Age*

7.	Country of Citizenship*

8.	List other countries with which you have strong ties or have lived in.

9.	How long will you live in Wilmington?*
	1 semester 1 year More than 1 year

10.	Academic Major*

11.	Would you be OK with a host who has pets (dog, cat, etc.)?*
	Yes No Other, please specify

12.	Are there any foods you can not eat for health, religious, or other reasons?*
	No, I can eat anything Yes, I can't eat the following foods

13.	Please list your hobbies and interests.*

14.	Explain WHY you want a host family and WHAT activities you would like to do with your host family.*