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Los Angeles Trip Registration

2019 LA Trip Registration

- All fields are required.

What trip would you like to participate in?

Personal Information

First Name:
Last Name:
Nickname:
Gender:FemaleMale
Date of Birth:

Passport Number:
Your Home Country:
Your Email Address:
Your Cell Phone Number:
Exchange Year:

Host Family Information

Host Parent 1:
Host Parent 2:
Address:
City:
State:
Zip Code:
Phone Number 1:
Phone Number 2:
Email Address 1:
Email Address 2:

Information From Country Of Origin

Home Address:
City:
State/Province:
Country:
Zip:
Phone Number:
Cell Phone:
Email:
Mother's Name:
Father's Name:

Medical Information

Insurance Provider:
Policy Number:
Do you have allergies?YesNo
If yes, allergic to what?
Do you take medications?YesNo
If yes, which medications?

Do you have dietary restrictions?YesNo
If yes, what are they?

Do you know how to swim?YesNo

Have you had swimming lessons?YesNo

Your T-shirt size:

Roommate Preference:

Terms & Conditions

View PDF. REQUIRED: *Please read and confirm your agreement with our Terms & Conditions:

I agree

Email

Phone Number

(503) 222-9803 in Portland
(877) 222-9803 Toll Free
Fax: (503) 227-7224

Address

1029 SW Washington Street Portland, OR 97205