Name(s) __________________________   ______________________________

Address _________________________________________  City_________________  Zip ____________

Phones ( Land)__________________  (Cell)________________   Email ___________________________

Age(s) _______________   Gender(s) ________________   Marital Status _________________________

Occupation(s) _____________________________________            Retired?  _______________________

Spanish Language Ability  _______none/poor  _______beginner  _______intermediate  ________fluent

How important is it for you to be matched with a Costa Rican host who speaks some English?

______Very  _____Somewhat  ______Not an issue, we can use dictionaries and sign language if needed!

Do you smoke?  ______   Do you enjoy an alcoholic beverage?  ____daily _____ on occasion _____never

Are you allergic to certain foods or do you require any special diet?  _____________________________

What foods do you prefer / dislike?  _______________________________________________________

Do you have ANY allergies?  ______________________________________________________________

Hobbies/Interests ______________________________________________________________________

_____________________________________________________________________________________

Do you have any preferred bed or sleep accommodations? (extra pillows, etc.) _____________________

How would you describe your activity level?  _____sedentary  _____good, but tire easily  _____fit/active

Are you able to climb 1)steep stairwells, 2)steps onto buses, 3) paved / unpaved hiking paths? _____________________________________________________________________________________

Do you have physical disability limitations? __________________________________________________

Do you have any known medical issues or take any special medications?  _________________________

_____________________________________________________________________________________

 Before departing, provide your health insurance policy info or, if none, provide purchased traveler insurance info:

carrier name __________________________ policy #_______________  valid dates______________

traveler ins. carrier _____________________ policy #________________ valid dates__________

Emergency Contact Information:  name_________________________  phone number_______________ email________________________  address________________________  relationship to me______________________________________

Recent photo(s) attached? (small digital preferred) _________________

Attach check(s) payable to Oregon Partners of the Americas; mail to OPOA Adult Exchange, 3106 N. Kilpatrick St., Portland OR 97217.

2017 Dues ($40) ________     2018 Dues($40)  ________  Nonrefundable Deposit ($50)  ________

What do you think makes a good house guest? ______________________________________________

Why do you want to travel to Costa Rica as a homestay guest?  _________________________________