Status & Checklist

HOMESTAY APPLICATION FORM

Status & Checklist

(Please tick X): [ ] New (never applied before) [ ] Repeat (six months or more between last homestay with TP)

Please fill-out all important aspects of this application form in order to allow us to help you arrange your homestay placement appropriately. We require all information to be completed to the best of your knowledge.

To: Homestay Applicant,

Thank you for considering the Homestay Program with Titan Planet Homestay. We invite you to join our exchange program to homestay abroad, where you will be benefited from the program and meet people around the globe.

You must submit the completed application form (please type or print in black ink)

Items to be submitted:

 Homestay Application Form (page 1 to 4)  Personal or Family Photos (Photos must be taken within 6 months)  Homestay Agreement, signed by the applicant or applicant parent/guardian(s) (page 5)  VISA Application Form - only apply to Japan Homestay application. (download from our website)  Insurance Form (download from our website)

You application may begin reviewing for placement upon we received of the above mentioned documents.

Please indicate the duration and country you plan to visit for homestay program:

Homestay Date from: to Destination: ( d d / m m m / y y y y ) ( d d / m m m / y y y y ) NOTE: Incomplete application won't be considered.

A. APPLICANT INFORMATION: m r o f

Name (漢字): n o i t

Name (English): a c i Gender: [ ] Male [ ] Female Marital Status: [ ] Single [ ] Married Others: l p p a

Date of Birth: Age: ( d d / m m m / y y y y ) y a

Religion: Race: Height: cm / ft. Weight: kg / lbs t s Occupation: e m o

Home Address: h

City/Town:

Postal/Zip Code: Province/State: Country:

Email Address:

Home phone Mobile phone - -

Passport number Passport Validity: ( d d / m m m / y y y y ) Passport issued at: on: ( d d / m m m / y y y y )

[ ] School [ ] College / University Name:

Education Level: [ ] Primary [ ] Secondary [ ] High School [ ] College [ ] University

Field of Study:

Visitor applicant:

Company Name:

Address:

Office number -

Please indicate your hobbies, special interest or abilities you have: (Please tick X)

[ ] swimming [ ] martial art [ ] cycling [ ] skating [ ] tennis [ ] soccer [ ] gymnastics [ ] cooking [ ] travel [ ] arts/crafts [ ] community service [ ] dance [ ] photography [ ] artwork [ ] computers [ ] musical instrument [ ] badminton [ ] table tennis [ ] diving [ ] singing [ ] magic [ ] other

B. LANGUAGE PROFICIENCY (Only fill in the language you know, others leave it blank) 话语话东 e 语语 a s i h 日 n n h 华廣 h h 台 e s y s

n 韩 i s a a

i i e c

i s n u e a i e a a i n l d s l i s n n n m r g l n s h a r a e s e Language g a e a i a u a o e r T t e t u n n p k e w d M r I d n m r F a k E G R S n o S n r o o I p t o a P o K a n H f M J a

C n o i

Speaking t a c

Writing i l p

Reading p a

A – Excellent B – Pass C – A little D – Not Able y a t s

C. EMERGENCY CONTACT PERSON (Please tick X) e m o

1. Name of parent/guardian: [ ] Mr. [ ] Mrs. [ ] Ms. [ ] Dr. h

Relationship:

Address:

IC Number:

Home phone Mobile phone - -

2. Name of parent/guardian: [ ] Mr. [ ] Mrs. [ ] Ms. [ ] Dr.

Relationship:

Address:

IC Number:

Home phone Mobile phone - -

D. LIST OF FAMILY (for accompany on the same trip only)

Name: Relationship:

Gender: Date of Birth: Age: ( d d / m m m / y y y y ) Passport number

( d d / m m mPassport / y y y y ) Validity: Passport issued at: on: ( d d / m m m / y y y y )

Important: Please recheck your email and phone number for any typo.

E. HOMESTAY PREFERENCE (Please tick X)  Host family preferable: With children [ ] Without children [ ] Does not matter [ ]  Are you willing to live with a family that has pets? Yes [ ] No [ ] Does not matter [ ]  Are you willing to live with a family that smokes? Yes [ ] No [ ] Does not matter [ ]

F. HEALTH STATUS (Please tick X)

Food or drinks, Restriction, if any (e.g. no pork, no alcohol and etc.): m

 Do you have Medical Insurance? Yes [ ] No [ ] If no, will you purchase insurance? Yes [ ] No [ ] r o f

 Do you smoke? Yes [ ] No [ ] IF YES, are you willing to smoke outside? Yes [ ] No [ ] n o i Do you drink Alcohol? Yes [ ] No [ ] t

 a c i l p

Do you have allergies? Yes [ ] No [ ] If yes, caused by: p a

y a

Do you have any physical disabilities? Yes [ ] No [ ] If yes, please explain: t s e

Do you require special medical treatment? Yes [ ] No [ ] If yes, please explain: m o h

G. APPLICATION QUESTIONNAIRES How did you know about us?

What do you wish to accomplish on this homestay / exchange program?

What are your main reasons for wanting to participate in this program?

Outline your travel experiences.

Please describe your experiences with team/group and why you think you would make a good team/group member in this exchange program?

Why do you want to become a Home stay Ambassador/students with Titan Planet, instead of joining the normal tour?

Please introduce yourself briefly? (Example: independent, shy, adventure person, involved in similar language, art and cultural activities, etc)

Have you participated in another Homestay Program before? (If YES, please brief it)

Additional comments, questions, concerns, requests.

H. STUDENT OR VISITOR HOMESTAY GUIDELINES

When staying with a host family, you will become a guest, and guests must follow household rules. Here are some of the m guidelines and responsibilities to help you make your homestay experience an enjoyable one. r o f

1. Always ask questions if you are not sure about something! It may take a few days to get to know each other. n o i

2. Do not bring strangers to the house without permission from the host family. t a

3. If you want to invite a friend home, please ask permission from your homestay family in advance if it is all right to do c i so and confirm the visiting hours with your host family. l p

4. Always let your host family know in advance, if you want to go out on your own and must inform exactly what time p a

you will be home. Host families can get extremely worried about your safety. 5. If you plan to eat out, please inform your host family at least 2 hours in advance or a day earlier and let them know y a that you will eat out. t s

6. Find out when you can receive calls and for how long you can use the phone. If you make long distance calls from e

the host family's home, you must use a calling card or make collect calls. m 7. Washing your laundry - consult with your host family upon arrival about how and when you can wash your laundry. o h 8. Bathroom – If you are sharing a bathroom with other members of the family, please find out when is the best time to have a shower. It is your responsibility to provide your own bathroom supplies such as towels, shampoo, body wash, toothpaste etc… 9. Cleanliness – You are responsible for keeping your room clean. You are expected to remove your plate and utensils from the table after meals. However, you are not required to do home chores such as baby sitting, gardening, house cleaning…etc 10. Don't forget to turn off the lights! Turn off the TV or radio when you are not using them. 11. You should have medical insurance that covers any medical expenses that may happen during your homestay abroad. Make sure to show proof of insurance and emergency contact details to a Titan Planet Homestay representative. Travel Insurance will be purchased by Titan Planet Homestay for your homestay trip as an additional protection which included in the package fee. 12. Neither the host family nor Titan Planet Homestay and International Homestay Organization take any responsibility for your medical or emergency medical expenses. 13. Also Titan Planet Homestay does not assume any responsibility for any injuries you suffered while in the host family's care. Please consider getting insurance that covers both health care and emergency medical. 14. If any physical or verbal abuse occurs, the student or visitor will be removed from the home immediately. The incident will be reported to the police and legal actions taken. (Applies to both the student/visitor or host family)

TITAN PLANET (1344704-H) Suite 663, MBE Bangsar Village, LG-11B, No 1, Jalan Telawi Satu, Bangsar Baru, 59100 Kuala Lumpur, Malaysia. Hotline: 019-663 8336 Fax: 03-2283 2505 Email: [email protected] Website: http://www.TitanPlanet.net form version 2010-1 Page 4 of 6 15. If you have any concerns that you cannot discuss with your host family, please contact your local Homestay Agency Representative and/or your parents or your guardian as soon as you can. 16. If you accompany your host family on holidays, outings, or trips, you must pay for travel arrangements, admission tickets and personal expenses. The host family will pay for accommodation and food.

By signing this application you acknowledge that you true and binding.

Applicant Signature:

(Please tick X): Do you agree and accept the homestay guidelines as stated above? Yes [ ] No [ ]

I. HOMESTAY PROGRAM DISCLAIMER / AGREEMENT

This homestay disclaimer applies to all participants in this homestay program including hosts, applicants, affiliates, students and visitors. I/We have read and understood the conditions and guidelines outlined on Titan Planet Homestay website and its applications.

I/We understand that Titan Planet Homestay including all company services, executives, employees and websites are acting as independent agents who are not guaranteeing the quality of the relationship between the homestay student / visitor and the host family, or between student and the educational institution, or other relationships.

I/We understand and assume any and all risks related to my participation in this program, and I/We agree to release and hold harmless to Titan Planet Homestay and each of their respective employees, agents, oversea homestay organization and representatives from any and all liability of claims should any injury, loss, or damage occur during this homestay or any other service offered.

I/We understand that if I/we participate in this program that I/we will purchase my own insurance whether medical, emergency, liability, damage, home, vehicle and/or any other types of insurance which may be necessary, should any m claims, damages or penalties arise. Contact your insurance broker or insurance provider for more details. r o f

I/We understand that Titan Planet Homestay do not assume any responsibility for any injuries, losses, damages, n o problems or accidents that might occur during a homestay or a program. I/We further understand that any actions that i t take place among the homestay family, oversea homestay organization and student / visitor are not sanctioned by Titan a c i

Planet Homestay nor do I/We hold Titan Planet Homestay responsible for any reason. l p p

I/We hereby declare and agree that the statement given above is true and correct. I/We understand that immigration a

status and period of stay to be granted are decided by the foreign immigration authorities upon my arrival. I/We y a understand that possession of visa does not entitle the bearer to enter foreign country upon arrival at port of entry if he t or she is found inadmissible. Titan Planet upholds a ZERO-TOLERANCE policy for alcohol, drugs, abuse, leaving the s group for any reason, harassment, lying or stealing. Visitors or Students may be sent home AT THEIR PARENTS'/OWN e m

EXPENSES if this occurs. I/We will observe Titan Planet and it foreign or attached homestay organization for all their o term and conditions, and the host family’s house rules. I/We have read and agree to accept this agreement / policy from h Titan Planet and sign on below.

(Please tick X): Do you agree and accept the homestay program disclaimer/agreement as stated above? Yes [ ] No [ ]

By signing this application you acknowledge that you are true and binding.

J. SIGNATURE

Applicant: Name: Signature Date:

Parent / Guardian (if applicant below 18 years old):

Agents / representative:

Name: Signature Date: m r o f

n o i t a c i l p p a

y a t s e m o h