Family Last Name, First Name State Student Name (if known) Form A: Host Family Composition Instructions: Please fill in all applicable fields. Information provided in this application will be used solely for AFS-USA purposes and will not be sold or distributed to third parties. When entering first and last name, enter name as it appears on passport, driver’s license or any official government ID. All household members living in the home for a total of 10 days or more, consecutively or non-consecutively, during the participant's program will be considered 'living in the home full time' and will be required to undergo a criminal background check if age 14 or older. This includes any children away at school who will be home on weekends and/or holidays. Please enter the preferred email address that you would like all important AFS communications to be sent to under Parent 1. When complete, save your work and go to Form B. Family Members No. Title Legal First Name Middle Name Legal Last Name Gender Relationship Birth Date Month Day Year Country of Birth Contact Phone Level of Education Live at home? Employer/School 1. / / / / / / / / / / / / / / / / 2. 3. 4. 5. 6. 7. 8. Parent Information Family of : Number of additional people living in the home full time : Please note: Each working member of the household must provide one phone number in addition to the residence phone Parent 1 Full Name Occupation Job Title Employer Primary Email Business Phone Mobile Phone Fax Parent 2 Full Name Mobile Phone Fax Occupation Job Title Employer Primary Email Business Phone Address Residence (please no PO Boxes, use Physical Address) Address 1: Address 2: City: State: Home Phone: Zip Code: Mailing Address, if different Country: Other Phone: State: Zip Code: Fax: 1. Type of home. 2(a). Is your residence part of a functioning business and/or do you have employees (i.e. caregiver, nanny, housekeeper) that have access to the main living quarters of your home? 2(b). If yes, please provide the employee’s typical work days/hours and indicate whether he or she 2015 Host Family Application- Form A Copyright © 2015 AFS-USA would be likely to interact with your hosted student. Note: Any employee with access to the living areas of the home must undergo a criminal background check. Please include any such person(s) in the 'Family Member' section above and add 'Employee' as their 'Relationship' in order to facilitate his or her background check. Placement Information 1. We are applying to host for a 2. Our family would like to host a 3. Our family would like to host a student from 4(a). Will the student share a bedroom? (can only share with one other individual of the same gender) 4(b). If yes, with whom and what is his/her age? 4(c). Will any member of your household be displaced from their current bed and/or bedroom? If yes, please explain 5. Would you feel comfortable hosting a student who follows a particular dietary restriction (ex. Vegetarian, Vegan, etc.)? 6(a). Does any member of your household follow any dietary restrictions? 6(b). If yes, please explain 7(a). Do you expect the student to follow any dietary restrictions? 7(b). If yes, please explain 8. Does any member of your household smoke? Inside the house? 9. What are your feelings about a student who smokes? 10(a). Do you have any pets? 10(b). If yes, please list the type, and number of pets. 11. What language is spoken at home? 12. What other languages are known by members of your household? 13. Other than hosting with AFS-USA, if you are currently hosting or have ever hosted with any of the high school exchange organizations on the drop down list below, indicate which organization(s) and year(s). High School Exchange Organization Year(s) Other Comments (i.e. what country you hosted, if you lived in another state at the time, etc.) (ex: 2012) Choose an item. Choose an item. Choose an item. 14(a). Is any member of your household an AFS returnee? 14(b). If yes, which member(s), year(s) and country(ies)? 15(a). Is any member of your household currently volunteering with, or employed by another high school exchange organization? Note: As per US Department of State regulations, a family may not host with one J-1 exchange organization while any family member is a volunteer or employee for another J-1 exchange organization. If the family member will no longer be working with the other organization by the AFS program start date, the family may be eligible to host with AFS. 15(b). If yes, please specify which organization 16(a). Is any member of your household interested in learning more about volunteering with AFS-USA? 16(b). If yes, which family member(s)? 17. How did you learn about being a host family? 2015 Host Family Application- Form A Copyright © 2015 AFS-USA