Host Family Application

HOST FAMILY APPLICATION

(Please print in ink or type) One per family. Must be completed prior to the student’s arrival and a copy of page 1-4 must be sent to the exchange student as a family profile per the Dept of State.

Student Name:______Rotary Club______

Host Mother:(Full Name) DOB:
Email: Mobile Tel:
Level of Education:
Employer: Job Title:
Address:
Point of Contact: Telephone No:
Host Father:(Full Name) DOB:
Email: Mobile Tel:
Level of Education:
Employer: Job Title:
Address:
Point of Contact: Telephone No:

Is this a single parent household? (Y/N)______

Home Mailing Address: / Physical Home Address:
Home Telephone: / Is the residence the site of a functioning business? (Yes/No)
Describe:

List number and type of family pets?______

Describe relevant behavioral or characteristic traits of any household member that could affect the successful integration of the exchange visitor into the household.______

______

List full name of all other persons living in your home.

Name Relationship DOBLevel of Education Profession

______

______

______

______

Exchange students cannot be placed with his/her relatives!

FamilyActivities: Language spoken in the home?______

Please list the hobbies and special interests for each family member: (e.g. camping, hiking, dance, crafts, art, music reading, sports etc) ______

Organizations and clubs to which your family belongs:______

Describe your expectations regarding the responsibilities and behavior of the student while in your home: (e.g. homework, chores, curfew, access to refrigerator and food, smoking, computer etc) . ______

Would you be willing to voluntarily inform the exchange visitor, in advance, of any religious affiliations of household members? (Yes/No)______

Would any member of the household have difficulty hosting a student whose religious beliefs were different from their own? (Yes/No)______

Of note, a host family may want the exchange visitor to attend one or more religious services or programs with the family. The exchange visitor cannot be required to do so, but may decide to experience this facet of US culture at his/her discretion.

Identify those personal expenses expected to be covered by the student:______

______

The Home: Describe your type of home (e.g. single family, condominium, duplex, apartment etc) and describe primary rooms. Photographs will need to be taken of your home by the Interviewer and must include the exterior, kitchen, student’s bedroom, student’s bathroom and family and living areas (Note: photographs are required by the Dept of State) .

Number of bathrooms______Will the exchange student share a bedroom (Yes/No)______

If yes, with which household resident:______

Describe the Student Bedroom______

Describe amenities to which the student has access?______Utilities?______

Diet: Does anyone in the family follow any dietary restrictions? (Yes/No)______If Yes, describe.___
______

Do you expect the student to follow any dietary restrictions? (Yes/No) ______If Yes, describe.______
______

Would you feel comfortable hosting a student who follows a particular dietary restriction? (ex: vegetarian, vegan, etc) (Yes/No)______

Will you provide three square meals daily? (Yes/No)______

School: High School the Student will attend:______Private or Public

Address:______Telephone______

Name and Email address of School Official:______

Approximate size of school:______Approximate Distance between School and your home:______

Approximate start date of school:______How will the student get to the school (e.g. bus, carpool, walk)______

Which, if any, of your children presently attend the school in which the exchange student will enroll.______

______

List sports/clubs/activities that your children participate in at the school.______

______

Does any member of your household work for the high school in a coaching/teaching or administrative capacity? (Yes/No) If Yes, describe______

Has any member of your household had contact with a coach regarding the hosting of this exchange student with particular athletic ability? (Yes/No)

If Yes, describe______

Would your family provide special transportation for extracurricular activities after school or in the evenings, if required? (Yes/No)______

Community: In what type of community is your home: (e.g. urban, suburban, rural, farm)______

City or Town website: ______Approximate Population______

Briefly describe your neighborhood and community, including points of interest______
______

______

______

Areas near your home to be avoided?______

Nearest Major City______Population______Distance______

Nearest Airport______

How did you learn about being a host family?______

If you have additional comments you would like to include, please use the space provided below:______

Do you know of other families that may wish to host students? If yes, please provide their contact information below:

Criminal History: (please attach additional sheets, if necessary)

Has any member of your household ever been charged with any crime? (Yes/No) ______

If Yes, Explain in detail______

______

Has anyone ever been subject to any court order involving any sexual, physical or verbal abuse including but not limited to any domestic violence or civil harassment injunction or protective order? (Yes/No)

If Yes, describe in full. Indicate date(s) of crime(s) and in which city and state each took place.

Have you or anyone in your household had any contact with any child protective service agency in the past? (Yes/No)

If yes, please indicate when and for what reason(s)

Addendum

The following information is required by the Dept of State and will be kept in confidence to be used solely for the purposes of ensuring that the basic needs of the exchange student can be meet, including three quality meals and transportation to and from school activities.

Average Household Annual Income:
(please check one) / _____Less than $25,000
_____$25,000-$35,000
_____$35,000-$45,000
_____$45,000-$55,000
_____$55,000-$65,000
_____$65,000-$75,000
_____$75,000 and above
Does anyone residing in the home receive any kind of public assistance? If yes, describe.
(financial needs-based government subsidies for food or housing)

Of note, host families cannot be either directly or indirectly paid by cash or other incentives. (e.g. gift cards for groceries, gasor retail, trips.

April 2011Page 1 of 5HF205 - Host Family Application – HFAudit 6