Host Family Univille

Student Name:

Nationality:

Photo ID:

Gender:

male

female

Special Requirements (e.g. disabilities):

no

yes

Which:

Cidade:

Country:

Course at Univille:

E-mail:

Exchange period (From):

/ /

(MM/DD/YYYY)

Exchange period (To):

/ /

(MM/DD/YYYY)

Mobility Program Coordinator:

E-mail:

Address (street, number, post code, city and country):

Exchange Framework:

Cooperation Agreement

other

(other) which?:

University of Origin:

Course at the University of Origin:

Accomodation Type

Please indicate how many months you will be needing accommodation:

Please, indicate your choice by order of preference (1st, 2nd, 3rd)

Host Family – Single room:

Host Family – Double room *:

Hostel – Private Accommodation:

* In this option you will be sharing the accommodation with someone of the same gender and similar age.

Language Skills

Language 1:

Nível:

basic

intermediate

advanced

fluent

Language 2:

Nível:

basic

intermediate

advanced

fluent

Language 3:

Nível:

basic

intermediate

advanced

fluent

Personal Information

Please, write a report on your daily routine, stories, the university, friends, family, travel etc. It is important to describe with many details as possible, then it will be easier to find suitable family profile.:

Signature::

Data:

/ /

(MM/DD/YYYY)