Host Family Application Form

There was a problem with your submission. Please correct the issues below

Requested Length of Homestay

Length of Stay *

Short-term Stay (One Semester)
School-year Stay

Applicant Contact Information

Applicant / Head of Household

First *

Middle *

Last *

Mailing Address

Address

City

State

Zip

Physical Address

Address

City

State

Zip

Phone Numbers

Home

Work

Cell

Spouse / Other Adult Contact Information

Spouse /Other Adult

First

Middle

Last

Phone Numbers

Home

Work

Cell

Emergency Contact Information

Emergency Contact Name

First Name

Last Name

Relationship

Family Members / Home Occupants

Please complete the following information for ALL occupants in the household, including the main applicant and other adult.

Applicant / Head of Household

First Name

Last Name

Gender

Date of Birth

Spouse / Other Adult

First Name

Last Name

Gender

Date of Birth

Child One

First Name

Last Name

Gender

Date of Birth

Grade in School

Child Two

First Name

Last Name

Gender

Date of Birth

Grade in School

Others Living In Household

Will anyone else be living in your home (namely relatives, roommates, boarders, other students, etc.) at any time during the Program?

Others Living In Household

Yes No

If yes, please explain:

Do you have a child that currently attends Mt. Blue High School?

Yes No

If yes, please list student name/s:

Personal Information

Marital Status

Married Single

Does Head of Household/Applicant work outside the home?

Full-time Part-time No

Head of Household/Applicant Occupation

If yes, occupation:

Does Spouse/Other Adult work outside the home?

Full-time Part-time No

Spouse/Other Adult Occupation

If yes, occupation:

How many students can you host at the same time?

List of pets/animals in the home (indoor, outdoor, both):

Are there tobacco users in the home?

Yes No

Will you allow a student to smoke outside?

Yes No

Do you or your spouse/other adult drink alcohol?

Yes No

If yes, please describe:

Have you hosted an international student before?

Yes No

Does your family attend church?

Yes No

If yes, to what extend to you attend church?

Active (2+ times a week) Average (1 to 2 times a week) Little (Occasionally) Inactive (Never)

Please note any additional religious beliefs and practices here:

Are you willing to accept a student with dietary restrictions?

Yes No

Does your family follow a special diet?

Yes No

If so, what type of diet do you follow?

Are you willing to provide transportation or arrange transportation for the student to and from school and after school activities?

Yes No

Describe a typical weekend in your home:

Preferences

What gender student would you prefer to host?

Female Male No preference

Recreation and Hobbies:

Please specify (sports, music, reading, etc.)

What is your biggest motivating factor for wanting to be a host family?

Please add any other detail about your family that you think will help us make the most suitable match:

Please describe your community:

Please describe your family rules and chores:

Please describe your family curfew:

Is any member of your household receiving any kind of public assistance?

Yes No

Have you had any contact with Child Protective Servies Agency in the past?

Yes No

Disclosure and Electronic Signature

Please be aware that you are under no obligation at this time to host an international student; however, by submitting this application, the host parents agree to the terms listed in the RESPONSIBILITIES AND EXPECTATIONS OF HOMESTAY PARENTS.

If the opportunity arises, we will be contacting you to continue the application process.

Electronic Signature

My typed name above constitutes my understanding that information submitted with and in support of this application may be disclosed to a screening and/or interviewing committee, which may include board members, administrators, other school staff, and members of the community. I give my consent to this disclosure.

* Required Fields

host family application form

Requested Length of Homestay

Applicant Contact Information

Spouse / Other Adult Contact Information

Emergency Contact Information

Family Members / Home Occupants

Others Living In Household

Personal Information

Preferences

Disclosure and Electronic Signature

Email