International Friendship Program Sign Up Form Student Details PeopleSoft ID: Family Name: First Name: English Name(if any): Preferred Contact Email: Date Of Birth: Age: Marital Status: Gender: Origin Country: Origin City: Street Address: Apt#: City: State: Zip: This is: My Address Friends Address Phone: Do not write any dashes between numbers Religion: Visa Type: Select Visa A-1 A-2 E-1 E-2 F-1 F-2 G-1 G-2 G-3 G-4 G-5 H-1B H-4 J-1 J-2 K-1 K-2 K-3 K-4 L-1 L-2 O-1 R-1 R-2 TN TD TPS Major: Degree: Family Details Are you married? Yes No If married what is the name of your spouse? Is your spouse here in Houston? Yes No If a student,provide major: Spouse's talents and hobbies Do you have children? Yes No If yes, are they here in Houston? Yes No What are their ages/age? Other Details Please list at least 3 of your hobbies or talents Are you a transfer from another school here in the USA? No Yes If yes, which school? Other countries you have lived in How long have you been in Houston? Do you have a car? Yes No How long you think you will be studying at the University of Houston? Do you have a part-time job on campus at UH? yes no In Houston, are you living with Parents Brother Sister Aunt Uncle Cousin Other Relatives None List foods you cannot eat If you are married and your spouse is here in Houston with you, you will be matched with a Houston family or married couple. If you are married but your spouse is not in Houston, or if you are single, you will be matched with either a Houston single (same gender as you), or a family, or couple. If you have a roommate who has also applied, you will both be matched with the same Houston person or family. I would like to participate in the voluntary program because I give permission to: I agree I don't agree *State law requires that you be informed of the following: (1) with few exceptions, you are entitled on request to be informed about the information the University collects about you by use of this form; (2) under sections 552.021 of the Government Code, you are entitled to receive and review the information; and (3) Under section 559.004 of the Government Code, you are entitled to have the University correct information about you that is incorrect. Time Commitment Since we always have more international students applying for this program than we have Houston families to meet with them, it's important you be willing to have or make time to meet several hours once a month with your Houston family. Will you have or will you make time in your schedule to meet once a month for several hours with your Houston ‘family,’ couple, or single? Yes No International Student and Scholar Expectations, Risk and Liability Waiver As a student or scholar, I am expected to be a respectful, gracious guest. I am also expected to be punctual and honor your host’s time. I am fully aware that there are inherent risks to myself and others involved with this activity, including physical or emotional injury caused by incidents during a monthly social event together, transportation to and from the host home or other location, or emotional distress caused by the student or host. I agree to hold harmless indemnities from any and all liabilities, claims, demands, injuries (including death), or damages, which may occur to myself, other participants, and third-persons as a result of my participation in the International Friendship Program. I understand I can choose not to sign this document and free myself from its terms by simply not participating in the activity. Media Release "I hereby grant International Student and Scholar Services at the University of Houston the right to use any written comment or testimony, recording of my voice and/or likeness for use in all media projects pertaining to the International Friendship Program. I grant International Student and Scholar Services the full and irrevocable right to produce, copy, and distribute my written testimony, voice and/or likeness in connection with the above project(s) by means of a written request, videotape, photography or any similar electronic or mechanical method. I acknowledge that the pictures or recordings taken during this experience become the sole and exclusive property of the University of Houston and I agree to hold International Student and Scholar Services harmless from and against any and all claims, liabilities, losses or damages that may arise from the use of my voice or image in the project." I agree to this statement I understand and agree to the terms listed above. I acknowledge and represent that I have read it, understand it, and agree to these conditions voluntarily as my own free act and deed. Initials