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