Temple University Intensive English Language Program
APPLICATION FOR TEMPLE UNIVERSITY HOMESTAY PROGRAM  
211 1700 North Broad Street, 1700 North Broad St., Philadelphia, PA 19122   
http://www.temple.edu/ielp   (215) 204-7899
  

Semester:  Spring / Summer / Fall  

Your approximate arrival date: ___________________  

1.  Student Name:  
      Mr./Mrs./Ms. _________________________________           Female     Male 
      CIRCLE ONE                   LAST                         FIRST             

2.      Mailing Address:  

________________________________________________________________
         APT NUMBER/STREET NO/POST OFFICE BOX NUMBER /STREET NAME               

     ________________________________________________________________
             CITY                                    STATE/ PREFECTURE/PROVINCE                            ZIP CODE

  _______________________________________________________
          COUNTRY

  3.  Birthday:         /         /           4. Age: _____ 5.  Nationality: ____________   
                MONTH   DAY   YEAR

    4.    Do you have any medical or physical requirements?            Yes     No

       Are you taking any medicine?                                                    Yes                No       
       If yes, please explain

__________________________________________________________________    

 _________________________________________________________________ 

5.  Do you have allergies?                           

Food         Yes     No _____________________

Animals    Yes     No ____________________

Medical     Yes    No  ____________________  

 6.  Do you smoke?     Yes      No                       

      Most host family homes are non-smoking. If you do smoke, you will be required to smoke
       outside their homes.  

7.      Would you accept a host with children under age 6?    Yes /  No     If no, please explain ____________________________________________________________

      ____________________________________________________________  

8. Would you be comfortable in a home that has indoor pets?     Yes /  No     If no, please
 indicate which one(s). _____________________________________________

9.  Are there any types of food that you cannot or will not eat?                   
        _________________________________________________________________      

10.   How long do you plan to study in USA? ___________________________       

11.   Do you have any friends or relatives living in the U.S. or Canada?      Yes               No  

 Name/Relation: _________________________(_____________)     Phone:___________________

Address:  

______________________________________________________________
     APT NUMBER/STREET NO/POST OFFICE BOX NUMBER /STREET NAME                

  

     ________________________________________________________________
             CITY                                STATE/ PREFECTURE/PROVINCE                        ZIP CODE

  ______________________________________ 
                                                         COUNTRY      



Temple University Intensive English Language Program

LETTER OF SELF INTRODUCTION 

In the space below, please write a brief letter of introduction to your host family.  Please write 
about any special interest, such as sports, talents, or hobbies you may have.

 

 Introduction:                                                                                                                                   

________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________

What are some things about your culture that you would like to share with your host family?

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

What kinds of activities would you like to do with your host family?  

________________________________________________________________________________________________________________________

What are your future goals / plans / career interest? ____________________________________________________________________________________________________________________________________

 

 

By signing below, I acknowledge that I have read and understand this waiver and that 
by signing it, I surrender valuable rights, which is done freely and voluntary.

Moreover, by signing below, I/we acknowledge that I/we have read and understand this waiver 
and that by signing it, I/we surrender valuable rights, which is done freely and voluntarily.    

  1. RELEASE, WAIVE, DISCHARGE AND AGREE NOT TO SUE, Temple University-of 
    the Commonwealth System of Higher Education and all its successors, assigns, affiliates, 
    officers, directors, employees and agents (“Temple”) from all manner of actions and 
    causes of action, suits, debts, accounts, judgments, claims and demands whatsoever in 
    law or equity, and attorney’s fees, including all claims arising out of any incidents 
    involving personal injury in any way by reason of participation in the program;  
  1. ASSUME RESPONSIBILITY FOR HIS/HER OWN SAFETY AND ANY AND ALL RISKS 
    involving or arising from his/her participation in the Program, including the negligent or 
    deliberate act of another person;  
  1. INDEMNIFY, DEFEND AND HOLD TEMPLE and its officers and employees and agents 
    harmless from any and all claims, causes of action, damages, judgments, costs and 
    expenses, including attorney’s fees, whatsoever, arising from his/her participation in 
    the program.

  _____________________________  
Name  

_____________________________                                        _________________  
Signature                                                                                                    Date

_____________________________  
Name  

_____________________________                                       _________________
Signature                                                                                                   Date                                           

PLEASE E-MAIL THIS APPLICATION TO:   Dennis Serge at dserge@temple.edu                             

OR FAX THIS APPLICATION TO:     (215) 204-3892                                       

 Please note: In most cases, we can provide Homestay accommodations for only single 
 (one person) applicants.