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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: Grade/Interests:
Children: Age: Gender: Grade/Interests:
Children: Age: Gender: Grade/Interests:
Children: Age: Gender: Grade/Interests:
      
 
Family Pets:      *Does anyone in your family smoke?:
*Will student share a room?      If so, with whom?:
Please check your family's activities and interests:

Other:
Why do you wish to host an exchange student?:
                           
Please list 2 personal references:
*Name:      *Phone:
*Name:      *Phone: