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Host Family Application Form

Parent Contact Information

Parent 1 Name *

Parent 1 Date of Birth * +

Parent 2 Name

Parent 2 Date of Birth +

Home Address - Street *

Street Address (Line 2 - Apt. #)

City/Town *

State *

Zip Code *

Home Telephone Number *

Parent 1 Occupation *

Parent 1 Cell/Mobile Phone

Parent 1 Email Address

Parent 2 Occupation

Parent 2 Cell/Mobile Phone

Parent 2 Email Address

American Host Family Information

Family Religious Affiliation * 🛈

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

+-

If you have children, do they all live at home?

Yes, all children live at home

No, some children live outside of home (please elaborate below)

N/A (Not Applicable)

Please indicate if any of your children do NOT live at home *

Does your family have pet(s)? *

Yes

No

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

+-

Does anyone in your family smoke? *

Yes

No

Family Interests - Please check all of your family interests and activities. Select as many as you wish. *

Home Information

Number of Bedrooms *

Number of Bathrooms *

Will the Student Have a Private Room? *

Yes

No

Will the Student Have a Private Bathroom? *

Yes

No

If the bathroom is shared, with whom will the student be sharing the bathroom?

Will the student have a closet in his/her room? *

Yes

No

Is there an internet connection in your home? *

Yes

No

Will the student have a quiet place to study? *

Yes

No

Please briefly describe your family's neighborhood *

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

Do you have any previous experience hosting students? If so, please explain.

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

Please provide photos of the following or email them separately to our Homestay Coordinator. (If you have already sent photos or will send directly, you may ignore this question). Photos: 1. Members of the Host Family 2. Front of the House 3. Back(yard) of the House 4. Living Room 5. Kitchen 6. Dining Room 7. Student Bedroom 8. Student Bathroom

Transportation

How will 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 (time)? *

References - Please Provide Two References

Reference 1 Name *

Relationship *

Reference 1 Telephone Number or Email Address *

Reference 2 Name *

Relationship *

Reference 2 Telephone Number or Email Address *

Host Parent Signature

Thank you to you and your family for your interest in our homestay program and for taking the time to fill out this form. We sincerely appreciate your interest in opening your home to our students.

With your signature below, you acknowledge that all of the above information has been completed accurately. Thank you!

Host Parent Signature * 🛈

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