Host Family Name:
First Name:
husband
wife
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
E-mail:
(required)
Husband's Occupation:
Business Phone:
Wife's Occupation:
Business Phone:
Please list all children of the family living at home, and any other persons or family members living
in the household:
Name:
Gender/Age:
Relationship:
Interests:
Name:
Gender/Age:
Relationship:
Interests:
Name:
Gender/Age:
Relationship:
Interests:
Name:
Gender/Age:
Relationship:
Interests:
Name:
Gender/Age:
Relationship:
Interests:
Name:
Gender/Age:
Relationship:
Interests:
Will student be sharing a room? Yes:
No:
If yes, with whom?
If your family has pets, please specify type and number:
Will you permit smoking? Yes:
No:
If yes, Inside:
Outside only:
Preferences regarding student: Male:
Female:
No Preference:
Family interests and hobbies:
International travel experiences:
Foreign languages spoken, if any:
Please give the names and phone numbers of 2 local references:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone: