Basic Family Information:

a. Host Family Member—Full name and relationship (children and adults) either living full-time or part-time in the home or who frequently stay at the home)

b. Date of Birth (DOB) of all family members

c. Street Address

d. Contact information (telephone; e-mail address) of host parents

e. Employment—employer name, job title, and point of contact for each working resident of the home

f. Is the residence the site of a functioning business? (e.g., daycare, farm)

g. Description of each household member (e.g., level of education, profession, interests, community involvement, and relevant behavioral or other characteristics of such household members that could affect the successful integration of the exchange visitor into the household)

h. Has any member of your household ever been charged with any crime?

Household Pets:

a. Number of Pets

b. Type of Pets

Financial Resources:

a. Average Annual Income Range: Less than $25,000; $25,000-$35,000; $35,000-$45,000; $45,000-$55,000; $55,000-$65,000; $65,000-$75,000; and $75,000 and above. Note: The form must include a statement stating that: “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”

b. Describe if anyone residing in the home receives any kind of public assistance (financial needs-based government subsidies for food or housing)

c. Identify those personal expenses expected to be covered by the student

Diet:

a. Does anyone in the family follow any dietary restrictions? (Y/N)

If yes, describe:

b. Do you expect the student to follow any dietary restrictions? (Y/N)

If yes, describe:

c. Would you feel comfortable hosting a student who follows a particular dietary restriction (ex. Vegetarian, Vegan, etc.)? (Y/N)

d. Would the family provide three (3) square meals daily?

High School Information:

a. Name and address of school (private or public school)

b. Name, address, e-mail and telephone number of school official

c. Approximate size of the school student body

d. Approximate distance between the school and your home

e. Approximate start date of the school year

f. How will the exchange student get to the school (e.g. bus, carpool, walk)?

g. Would the family provide special transportation for extracurricular activities after school or in the evenings, if required?

h. Which, if any, of your family's children, presently attend the school in which the exchange visitor is enrolled?

If applicable list sports/clubs/activities, if any, your child(ren) participate(s) in at the school

i. Does any member of your household work for the high school in a coaching/teaching/or administrative capacity?

j. Has any member of your household had contact with a coach regarding the hosting of an exchange student with particular athletic ability?

If yes, please describe the contact and sport.

Community Information:

a. In what type of community do you live (e.g.: Urban, Suburban, Rural, Farm)

b. Population of community

c. Nearest Major City (Distance and population)

d. Nearest Airport (Distance)

e. City or town website

f. Briefly describe your neighborhood and community

g. What points of interest are near your area (parks, museums, historical sites)?

h. Areas in or near neighborhood to be avoided?

Home Description:

a. Describe your type of home (e.g., single family home, condominium, duplex, apartment, mobile home) and include photographs of the host family home's exterior and grounds, kitchen, student's bedroom, student's bathroom, and family and living areas.

b. Describe Primary Rooms and Bedrooms

c. Number of Bathrooms

d. Will the exchange student share a bedroom? (Y/N)

If yes, with which household resident?

e. Describe the student's bedroom

f. Describe amenities to which the student has access

g. Utilities

Family Activities:

a. Language spoken in home

b. Please describe activities and/or sports each family member participates in: (e.g., camping, hiking, dance, crafts, debate, drama, art, music, reading, soccer, baseball, horseback riding)

c. 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/E-Mail)

Would you be willing voluntarily to inform the exchange visitor in advance of any religious affiliations of household members? (Y/N)

Would any member of the household have difficulty hosting a student whose religious beliefs were different from their own? (Y/N) 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.

How did you learn about being a host family?

References:

[75 FR 65984, Oct. 27, 2010]