Host Family Application Part 1 Office Use Only LN GR CO FN ID ST LR C
1.   Host Parents    PLEASE PRINT CLEARLY IN BLACK INK OR TYPE, AND RETURN TO LOCAL CONTACT PERSON.
Last Name(s) Father Mother     Parents are: Married Divorced Separated Widowed Single Other Home Tel:
E-mail:   Home Fax:       Address
City     State Zip
Father's Age  Father's Birthdate   Occupation Work Tel:   Mother's Age Mother's Birthdate  Occupation Work Tel:
Nearest Airport Emerg. Tel:
2.   Interests/Activities      In the area provided below, list activities, sports, and hobbies in which your family participates. Please also list who.
If you have any animals, please indicate if inside or out:
3.   Children - list all    If you have more than six children, please list on a separate sheet of paper & include all information below.
First Name Gender Birthdate (MM/DD/YY) At Home YesNo YesNo YesNo YesNo YesNo YesNo If there will be others staying in your home during your student's stay, please tell us who they are, their age(s), and for how long: Who will be the main companion(s) of your student? Does he/she work? Will your student have opportunities to meet teenagers?YesNo How? Will the student have his/her own room?YesNo (Sharing a room is fine, but student must have his/her own bed.) Local high school to be attending: Name    Address City      StateZip TelephoneFax
4.   Additional Information    Please check appropriate spaces.
We do not want a smoker    We will accept a smoker    Student may smoke outdoors only We are:     Catholic      Protestant    Jewish    Other    None    We attend:     Regularly    Occasionally    Rarely   Do you want the student to attend with you?    Yes      No    Does not matter We live:    on a ranch    on a farm  in a rural area  small town (5,000-50,000) small city (51,000 to 250,000) in/near large city