1. Last (family) name as on passport:
2. First name as on passport:
3. Middle name(s) as on passport:
4. Date of birth (month/day/year):
5. City of birth:
6. Country of birth:
7. Country of citizenship:
8. Do you have an international passport? Yes No
9. Full address (zip code, city, street, etc.):
10. Phone number:
11. E-mail address(es):
12. Skype name:
13. Name of high school:
14. Grade/year at school:
15. Field of study (if applicable):
16. Any other relevant educational, academic and professional experience or training:
17. Active memberships, special interests, or extracurricular activities:
18. Future study or career plans:
19. Previous travel or study experience in the United States (Please include dates and purpose):
20. Medical, physical, dietary, or other personal considerations (e.g. allergies):