Form for host family

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.)
School/Occupation
____________________

Age
Date of Birth
Living at home
_____ ____________ __________________

Yes

No

____________________

_____

____________ __________________

Yes

No

____________________

_____

____________ __________________

Yes

No

____________________

_____

____________ __________________

Yes

No

List pets you have in your home?
..............................................................................................................................
Are they located in home?
Yes
No

Does anyone smoke inside home?

Yes

No

Desribe your family points of interest (recreational, cultural, musical, etc)?
.............................................................................................................................
.............................................................................................................................
Briefly describe your home and neighborhood?
..............................................................................................................................
..............................................................................................................................
..............................................................................................................................
EDUCATION
First Host Parent

Second Host Parent

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?
Yes
No If yes, please explain ...............................................................
..............................................................................................................................

..............................................................................................................................
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
_____________________