Date

Surname

Given Name

English Name

Date of Birth (m/d/yr)

Age

Sex:   

       [  ] Male       [  ] Female

Street Address

Telephone (contact)

Telephone (other)

City

State

Zip Code

E-mail

First Language

Other Languages Spoken

Describe any medical conditions that may require immediate medical attention

Your answers to the questions below will help your instructor better know how to guide you.

What city and country do you come from?

Have you ever been away from your family for a long period of time? If yes, for how long?

Describe any concerns you have about living in the USA:

Please describe any jobs or work experience you have had.

Please describe your education.

What is your religion? How often do you attend religious services?

What are your activities/hobbies?

[  ] Sports;  [  ] Theater;  [  ] Music;  [  ] Dance;  [  ] Art;  [  ] Computer/Internet;  [  ] Cooking;  [  ] Fitness

Please provide any further information you feel would be useful.