PBHS/LCNL EXCHANGE PROGRAM
Matching Form
2014-2015
STUDENT INFORMATION
Last name
⎕Male
First name
Date of birth (month / day / year)
Middle name or initial
Nationality
First language(s)
⎕Female
Home address (street, city, state, and ZIP code)
Home telephone
Student cell phone (if available)
Student email address (please put an address that is checked at least once a day)
How would you describe your level of French?
⎕ Excellent (AP/native)
⎕ Good (4-5 yrs of study)
Have you ever traveled abroad? ⎕ Yes ⎕ No
⎕ Fair (2-3 yrs of study)
⎕ Beginner (0-1 yr)
If “Yes”, to which countries? ________________________________________________________
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PARENT/GUARDIAN INFORMATION
Parent/guardian #1
Last name
Relationship to student
First name
Cell phone
Work phone
Email address(es) (please put an address that is checked at least once a day)
Parent/guardian #2
Last name
Relationship to student
First name
Cell phone
Work phone
Email address(es) (please put an address that is checked at least once a day)
Parents/guardians:
Would you accept hosting an exchange student of the opposite sex of your child? ⎕ Yes
⎕ No
HOST FAMILY INFORMATION
Family members’ names
Relationship to student
Age
Occupation
STUDENT PERSONAL INFORMATION
1. Which words best describe your personality? ______________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
2. Do you like outdoor activities?
⎕ very much
⎕ a little
⎕ not at all
Which ones do you like? _____________________________________________________________________________________________________________
3. Do you like sports?
⎕ very much
⎕ a little
⎕ not at all
Which ones do you like? _____________________________________________________________________________________________________________
4. Do you play a musical instrument and/or sing?
⎕ yes
⎕ no
Which instrument(s)? _______________________________________________________________________________________________________________
5. Your favorite type(s) of music: _________________________________________________________________________________________________________
6. Your favorite musicians/groups: ________________________________________________________________________________________________________
7. Do you enjoy cooking? ⎕ yes ⎕ no (If yes, we suggest you bring some recipes with you so you can cook a meal for your host family.)
8. Check off some of your hobbies: ⎕ watching TV ⎕ going to movies ⎕ biking
⎕ music ⎕ Internet
⎕ photography
⎕ hiking
⎕ reading ⎕ arts & crafts
⎕ others: _______________________________________________________________________________
Additional comments/things that your host family should know about you:
STUDENT MEDICAL INFORMATION (for the French host family)
1. Do you have any allergies? ⎕ Yes ⎕ No
If “Yes”, please list them here:_______________________________________________________
______________________________________________________________________________________________________________________________________________
2. Do you take any medication on a regular basis? ⎕ Yes ⎕ No
If “Yes”, please list the name(s) and dosage(s) of the
medication(s): _____________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
3. Do you require a special diet, or are they any foods you cannot eat for religious or health reasons? ⎕ Yes ⎕ No
If “Yes”, please describe: _________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
4. What foods do you not like to eat? ____________________________________________________________________________________________________