Академический Документы
Профессиональный Документы
Культура Документы
This information will be kept confidential and will not be shared with other program participants
5. -
Parents
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Who lives in your household (parents, -
9
siblings, extended family, staff)? -
-
-
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No
Yes
10 Do you have a part-time job? ✓
•
Many Americans have pets, usually dogs and cats. Please indicate whether would be
14
comfortable living in the following situations (choose all that apply to you):
o I do not want to observe a religion while in the United States (go to question 18)
o I want to practice my religion in the United States (choose one option below)
o I am curious to see religious services of my faith in the United States
o I would like the opportunity to pray or attend services of my religion regularly
✓ It is very important to me to have the opportunity to pray or attend services regularly
17 Please specify which religious services you would like to attend:
I’m a Protestant Christian . My church is The Nusantara Evangelical Reformed Church ( GPIN )
If your host family attends religious services, they will invite you to join
Yes
18 them. This would be a good cultural exchange opportunity. Are you No
•
interested in doing this if the opportunity arises? ✓
19 Yes No
Do you have any allergies?
✓ •
1. Dust
If you have allergies, what are you allergic to?
20 2. -
(For example: pollen, shellfish, peanuts, cats, dust)
3. -
Allergy Treatment
Please list any treatment for allergies, if 1. Dust Using mask
21 applicable (please use additional space if
needed). 2. -
No Goat’s meat
List your dietary restrictions or preferences, if
any. (For example: vegetarian, no pork, kosher, No cat’s meat
22
halal, no shellfish.) We will try our best to
accommodate you.
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Do you have any physical limitations we should
23 be aware of (example: hard of hearing)? Please
list any.
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Do you have any medical conditions we should
24 know about (example: Diabetes, Asthma)?
Please list them, plus any relevant information.
1. -
2. -
Please list any medications you take and
25 3. -
dosages (please use additional space if needed)
4. -
5. -
Do you use social networking sites such as Yes No
26
Facebook or Twitter? ✓ •
Yes No
28 Do you have access to high speed internet? ✓ •