Thanksgiving Homestay Trip Registration Form
Please answer all questions and sign your name. Please print clearly and return this application by Friday, October 31, 2014 to:

International House Office of Programs and External Relations 1414 East 59th Street Chicago, Illinois 60637 Male Family Name First Name Age Female Circle One

Street Address

City

State

Zip Code

Phone Number (with area code)

Email Address

University

Field of Study

Date You Entered USA

Nationality

Hobbies/Interests Single Married Circle One Religion (Optional) Allergies or Medical Conditions: Are you bothered by household pets: Have you attended the Program before (Circle One)? *If Yes, Year(s) Name of affiliated institution: Student ID Number:
Please Note: Every participant MUST provide a student ID number on their application as proof of their enrollment in the school

Smoker

Non-smoker Circle One

Dietary Restrictions:

Yes

No Town(s)

Please list all family members who will accompany you on the trip: Name Age Male or Female Relationship (Spouse, Child)

Acceptance of Risk As a participant in the International Fellowship Program, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume responsibility for any injuries, damages or loss which I, my spouse, or any member of my family may sustain as a result of participating in any and all activities connected with or associated with the International Fellowship Program. I acknowledge that the International Fellowship Program is providing me with an educational opportunity and I will hold The University of Chicago, International House, the International Fellowship Program community organizations, and host families blameless for any occurrence resulting there from. I also understand that The University of Chicago, International House, the International Fellowship Program community organizations, and host families do not provide accident, sickness, or medical insurance for me or my family and that it is my responsibility to maintain such insurance for my benefit, if I so desire. I further agree that participation in any activity will be at my or my family’s own discretion and judgment. I am 18 years of age or older. I am the parent or guardian of any children who will accompany me. I have read and fully understood the above Acceptance of Risk. I understand that this is a four day program and agree to participate in the program for all four days. I understand that the $35.00 fee that I am submitting with this application is non-refundable.

Participant

Date

Spouse

Date