Rotary International District 5100 Youth Exchange Committee

Rotary International District 5100
Youth Exchange Committee
Located in Northern Oregon and Southern Washington, USA
www.youthexchange5100.org
“Service Above Self”
Host Family Application – Long Term
Host Family:_____________________________________ Host Club:__________________________________
Address_______________________________________City____________________State_______Zip________
List all members of the Host Family (living full-time or part-time in the home or who frequently stay at the home)
Name (First and
Last)
Relationship
Date of
Birth
Education
Profession
Interests
Community
Involvement
Religious background or affiliation:_______________________________________________________________
Please indicate foreign language background, if any, for family members:________________________________
__________________________________________________________________________________________
Have family members lived or traveled abroad? If so, outline which member(s), the year and where they went:
Organizations and clubs to which family members belong:
Please indicate the following – My family can receive a: ____Boy ____Girl ____Either
Would prefer to host a student in the: ____Fall ____Winter ____Spring ____Summer
Please indicate your feelings about a student who smokes:
____Will receive smoker ____Prefer non-smoker, but will accept smoker ____Will not receive smoker
LTEP HF Form 4
1 of 5
HF Long Term App. Rev 2.22.2011
How did you learn about being a host family?
Indicate briefly you main reasons for wishing to participate in this type of program:
Please describe other hosting experiences you have had:
Financial Resources:
Average Annual Income Range:
____Less than $25,000
____$25,000 - $35,000
____$35,000 - $45,000
____$55,000 - $65,000
____$65,000 - $75,000
____$75,000 and above
____$45,000 - $55,000
Note: The income data collected will be used solely for the purposes of ensuring that the basic needs of the exchange students can
be met, including three quality meals and transportation to and from school activities.
Describe if anyone residing in the home receives any kind of public assistance (financial needs-based
government subsidies for food or housing):
Identify those personal expenses to be covered by the student:
Diet:
Does anyone in the family follow any dietary restrictions? ____YES ____NO If yes, please describe below:
Do you expect the student to follow any dietary restrictions? ____YES ____NO If yes, please describe below:
Would you feel comfortable hosting a student who follows a particular dietary restriction (Vegetarian, Vegan,
etc.)? ____YES ____NO
Would the family provide three (3) square meals daily? ____YES ____NO
LTEP HF Form 4
2 of 5
HF Long Term App. Rev 2.22.2011
High School Information:
School Name: ______________________________________________________
____Public ____Private
School Address: ___________________________________________ City____________________Zip_______
School Officials Name: _______________________________Phone_____________Email__________________
Approximate size of the school student body: __________
Approximate distance between the school and your home: ______________________________
Approximate start date of the school year: __________________________________
How will the exchange student get to the school (e.g. bus, carpool, walk)? _______________________________
Would the family provide special transportation for extracurricular activities after school or in the evenings, if
required? __________________________________________________________________________________
Which, if any, of your family’s children, presently attend the school in which the exchange visitor will be enrolled?
__________________________________________________________________________________________
If applicable list sports/clubs/activities, if any, your child(ren) participate(s) in at the school:
__________________________________________________________________________________________
Does any member of your household work for the high school in a coaching/teaching/or administrative capacity?
__________________________________________________________________________________________
Has any member of your household had contact with a coach regarding the hosting of an exchange student with
particular athletic ability? ____YES ____NO
If yes, please describe the contact and sport:______________________________________________________
Community Information:
In what type of community do you live: ____Urban ____Suburban ____Rural ____Farm
Population of community: _______________
Nearest Major City: _____________________________Distance_______________Population_______________
Nearest Airport: ___________________________________________________Distance___________________
City or town website: _________________________________________________________________________
Briefly describe your neighborhood and community area:
What points of interest are near your area (parks, museums, historical sites):
Areas in or near neighborhood to be avoided: ______________________________________________________
LTEP HF Form 4
3 of 5
HF Long Term App. Rev 2.22.2011
Home Description:
Is the residence the site of a functioning business? (e.g. daycare, farm) ____YES ____NO
If yes, please describe below:
Describe your type of home: ____single family home ____condo ____duplex ____apartment ____mobile home
Number of Bathrooms: ____________
Will the student share a bedroom? ____YES ____NO If yes, with whom? _______________________________
Describe the student’s bedroom:
Describe amenities to which the student will have access (e.g. swimming pool, computer, spa, bust stop within 3
blocks):
Utilities (drinking water source, heating method, electricity source and sewer system type):
Household Pets:
Number of Pets: _________ Type of Pets: ________________________________________________________
Family Activities:
Language spoken in home: ____________________________________________________________________
Please describe any additional activities and/or sports each family member participates in: (e.g. camping, hiking,
dance, crafts, debate, drama, art, music, reading, soccer, baseball, horseback riding)
Describe your expectations regarding the responsibilities and behavior of the student while in your home (e.g.,
homework, household chores, curfew (school night and weekend), access to refrigerator and food, drinking of
alcoholic beverages, driving, smoking, computer/internet/email)
LTEP HF Form 4
4 of 5
HF Long Term App. Rev 2.22.2011
Would you be willing voluntarily to 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
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 U.S. culture at his or her discretion.
If you have any additional comments you would like to include please use the space provided below:
Do you know of any other families who may wish to host students? If yes, please list their contact information
below:
If selected as a host family, do you agree to treat the student as your own son or daughter and to provide
appropriate parental supervision? ____YES ____NO
PLEASE NOTE: Your Host Family Orientation cannot be conducted until screening of the Host Family is
complete (including Interviews, Background Checks and Reference Checks).
Host Parents: (Please sign in BLUE ink)
Print Name
Signature
Date Signed
Print Name
Date Signed
Signature
Send copies of this form to the following:
Name __________________________________
Address _______________________________
City _______________ State ___________ Zip___________
E-mail __________________________________
LTEP HF Form 4
5 of 5
HF Long Term App. Rev 2.22.2011