Test Formie Form

test

Personal Information

Name

First Name

Nickname

Last Name

Date of Birth

Nationality

Gender

Male

Female

Email Address

Postal Address

Address 1

Address 2

City

ZIP / Postal Code

State / Province

Country

Home Phone

Please write below a brief letter of introduction to your host family. Your letter should include information about you, your family, your studies, your reasons for going on Viaa Exchange and your hopes and expectations for your time in The Netherlands.

Housing Information

Use five words to describe yourself:

Use five words to describe the people you would like to live with:

My hobbies are:

My vocational goals are:

Describe your knowledge of Dutch:

Do you smoke?

Yes

Would you prefer a home where the family members do not smoke?

Yes

Please explain:

Do you have any food or pet allergies, or any other diet or pet preferences we should take into account?

Yes

Please list these allergies/preferences:

Do you have any physical or mental limitations that your host family should know about?

Yes

Please list these limitations:

Would you like your host family to practice Dutch with you?

Yes

A few host families may have space for two students. If you would like to stay with a roommate, please list your roommate preference:

Do you have friends or acquaintances you would like to live close to? If so, please list their names:

Housing Family Options

First Choice

Family with older kids (12+ yrs)

Family with younger kids (0-12 yrs)

Couple with no kids (born, or at home)

Single Person

Second Choice

Family with older kids (12+ yrs)

Family with younger kids (0-12 yrs)

Couple with no kids (born, or at home)

Single Person

How do you feel about living with a single person (a host mom or a host dad)?

My day usually begins at:

My day usually ends at: