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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:
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:
Swimming
Museums
Theatre
Camping
Fishing
Shopping
Travel
Sports
Bicycling
Boating
Cooking
Concerts
Movies
Music
Computers
Aerobics
Other:
Why do you wish to host an exchange student?:
Please list 2 personal references:
*Name:
*Phone:
*Name:
*Phone: