Host Family Application

* Required Field

Student Name:
Coordinator:      Community:

                                           
*Last Name:                  *Home Phone:
*Address:
*City:      *State:      *Zipcode:
*Email:      Fax:

        
*Fathers Name:       Occupation: Phone:
*Mothers Name:      Occupation: Phone:

Children: Age: Gender: Male Female Grade/Interests:
Children: Age: Gender: Male Female Grade/Interests:
Children: Age: Gender: Male Female Grade/Interests:
Children: Age: Gender: Male Female Grade/Interests:

      
 
Family Pets:      *Does anyone in your family smoke?: Choose a value Yes No
*Will student share a room? Choose a value Yes No      If so, with whom?:

Please check your family's activities and interests: SwimmingMuseumsTheatreCampingFishingShopping
TravelSportsBicyclingBoatingCookingConcerts
MoviesMusicComputersAerobics Other:

Why do you wish to host an exchange student?:

                           
Please list 2 personal references:
*Name:      *Phone:
*Name:      *Phone: