General Information (Please print in ink or type) Address: City: State: ZIP/Postal Code: List all members of the Host Family (living full-time or part-time in the home or who frequently stay at the home) Name (First and Last) Relationship Date of Birth Education Profession Interests Community Involvement Religious background or affiliation: Please indicate foreign language background, if any, for family members: Have family members lived or traveled abroad? If so, outline which member(s), the year and where they went: Organizations and clubs to which family members belong: Please indicate the following-- My family can receive a: Boy Girl Either Please indicate your feelings about a student who smokes: Will receive smoker Prefer non-smoker, but will accept smoker Will not receive smoker How did you learn about being a host family? Page 1 of 5 Rev 2-1/07/16
Indicate briefly your main reasons for wishing to participate in this type of program: Please describe other hosting experiences you have had: Financial Resources Average Annual Income Range: Less than $25,000 $55,000 - $65,000 $25,000 - $35,000 $65,000 - $75,000 $35,000 - $45,000 $75,000 and above $45,000 - $55,000 Note: The income data collected will be used solely for the purposes of ensuring that the basic needs of the exchange students can be met, including three quality meals and transportation to and from school activities. Describe if anyone residing in the home receives any kind of public assistance (financial needs-based government subsidies for food or housing): Identify those personal expenses expected to be covered by the student: Diet Does anyone in the family follow any dietary restrictions? Y N Do you expect the student to follow any dietary restrictions? Y N Would you feel comfortable hosting a student who follows a particular dietary restriction (Vegetarian, Vegan, etc.)? Y N Would the family provide three (3) square meals daily? Y N Page 2 of 5 Rev 2-1/07/16
High School Information School Name: School Address: School Official: (City) (Zip) Name: Phone: Email: Approximate size of the school student body: Approximate distance between the school and your home: Approximate start date of the school year: How will the exchange student get to the school (e.g. bus, carpool, walk)? Would the family provide special transportation for extracurricular activities after school or in the evenings, if required? Which, if any, of your family s children, presently attend the school in which the exchange visitor will be enrolled? If applicable list sports/clubs/activities, if any, your child(ren) participate(s) in at the School: Does any member of your household work for the high school in a coaching/teaching/or administrative capacity? Has any member of your household had contact with a coach regarding the hosting of an exchange student with particular athletic ability? Y N If yes, please describe the contact and sport: Community Information In what type of community do you live: Urban Suburban Rural Farm Population of community: Nearest Major City: Distance: Population: Nearest Airport: Name: Distance: City or town website: Briefly describe your neighborhood and community area: Page 3 of 5 Rev 2-1/07/16
What points of interest are near your area (parks, museums, historical sites): Areas in or near neighborhood to be avoided: Home Description Is the residence the site of a functioning business? (e.g., daycare, etc.) Y N Describe your type of home: single family home condominium duplex apartment mobile home Number of Bathrooms: Will the student share a bedroom? Yes No If yes, with whom? Describe the student s bedroom: Describe amenities to which the student will have access (e.g. swimming pool, computer, spa, bus stop within 3 blocks)? Utilities (drinking water source, heating method, electricity source and sewer system type): Household Pets a. Number of Pets: b. Type of Pets: Family Activities Language spoken in home: Please describe any additional activities and/or sports each family member participates in: (e.g., camping, hiking, dance, crafts, debate, drama, art, music, reading, soccer, baseball, horseback riding): Page 4 of 5 Rev 2-1/07/16
Miscellaneous Describe your expectations regarding the responsibilities and behavior of the student while in your home (e.g., homework, household chores, curfew (school night and weekend), access to refrigerator and food, drinking of alcoholic beverages, driving, smoking, computer/internet/e-mail): Would you be willing voluntarily to inform the exchange visitor in advance of any religious affiliations of household members? Y N Would any member of the household have difficulty hosting a student whose religious beliefs were different from their own? Y N Note: A host family may want the exchange visitor to attend one or more religious services or programs with the family. The exchange visitor cannot be required to do so, but may decide to experience this facet of U.S. culture at his or her discretion. If you have any additional comments you would like to include please use the space provided below: Do you know of any other families who may wish to host students? If yes, please list their contact information below: If selected as a host family, do you agree to treat the student as your own son or daughter and to provide appropriate parental supervision? Yes No PLEASE NOTE: Your Host Family Orientation cannot be conducted until screening of the Host Family is complete (including Interviews, Background Checks and Reference Checks). Host Parents Signature Print Name Signature Date Signed Print Name Signature Date Signed Page 5 of 5 Rev 2-1/07/16