Prospective Host Family Application Form
Host Family Program
PERSONAL INFORMATION
First Host Parent _______________________________ Date of Birth (dd/mm/yy)
Second Host Parent ___________________________ Date of Birth (dd/mm/yy)
Family home address: ... ... ... Phone/Fax: ...
First Host Parent Second Host Parent
Mobile Ph. ______________________ _____________________
E-mail address ___________________ _____________________
Occupation ______________________ _____________________
Name/address/phone (not living with host family) to contact in case of emergency
... ...
Host Family’s Children (please indicate those not living at home)
Name (Mr./Ms.) Age Date of Birth School/Occupation Living at home
____________________ _____ ____________ __________________ Yes No
____________________ _____ ____________ __________________ Yes No
____________________ _____ ____________ __________________ Yes No
____________________ _____ ____________ __________________ Yes No
List pets you have in your home?
Does anyone smoke inside home? Yes No
Desribe your family points of interest (recreational, cultural, musical, etc)? ...
Year _______________________ ________________________
Year _______________________ ________________________
Year _______________________ ________________________
How many students can you accept for Host Family Program (max. 4 students)?
...
How do you feel about accepting student who holds different religion beliefs of your own or who does not practice a religion?
... ...
HEALTH
Are all family members in a good physical and mental health condition? Yes No
... ...
Have you or any member of your family ever been charged or convicted of a crime?
Yes No
If yes, please explain (who and what circumstances)
... ...
Do you speak english? Yes No
If yes, please indicate ...
Beginner Intermediate Advanced
If you are accepted as a host family, will you be able to begin corresponding with the assigned student immediately? Yes No
Has any member of your family participated in an international student exchange program or studied overseas before?
...
How would you describe your family personality (conservative, outgoing, liberal, etc)?
...
Do you feel hosting a person with different language and culture can enrich your family’s life experience? Yes No
How? ... ... ...
We have reviewed the Rules for Host Family Program and agree to host a foreign student under the conditions outlined in the signed application form
First Host Parent
Date Name Signature
___________________ ________________________ _____________________
Second Host Parent
Date Name Signature
