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HOST FAMILY Exchange Form

Select your school *

Host Family Information (your family)

Student Name *

Phone Number

Email Address

Parent Name * 🛈

Phone Number *

Email Address *

Parent Name * 🛈

Phone Number

Email Address

Home Address - Street *

Home Address - City/Town, State *

Zip Code *

Home Telephone Number

Please list all children in your family by Name, Gender, and Age * 🛈

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Please list any other adults (Age 18 or older) who are currently living in your home. Please list by name, gender, age, and relation. * 🛈

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Please upload: 1) Student photo(s); 2) Family Photo(s). (Maximum of 5 total photos)

Home information

Number of Bedrooms *

Number of Bathrooms *

Will the Student Have a Private Room? *

Yes

No

Is there an internet connection in your home? *

Yes

No

Does your family have pet(s)? *

Yes

No

If your family has pets, please list them here (indicate pet name and type of animal) 🛈

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Please briefly describe your family's neighborhood *

What are the basic rules for a teenager in your home? *

Is there anything else you would like to share about your family? *

Transportation

How does student usually get to and from school? *

Distance from Home to School (approximate, miles) *

How long does it typically take to get to/from school? *

Signature

By signing this form you agree that this form be shared with the school and the family of the student who will stay with you. *

Parent 1 Signature * 🛈

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Parent 2 Signature * 🛈

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