Part 1- Host Family Composition

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1 Part 1- Host Family Composition Thank you for applying to be a host family for Fredericksburg Academy! Please be sure to fill in all applicable fields. Please be sure to enter the preferred address to which all further notifications will be sent under Host Parent 1. Please complete the table below for all household members who will be living at home for a total of 10 days or more during the international student s program; please be sure to answer yes to the questions living at home?. This includes children away at school or university who will be home on weekends and/or holidays. All household members ages 14 and older will be required to undergo a criminal background check. No. Title Legal First Name 1. Birth Date (MM/DD/YY) Middle Name Country of Birth Last Name Gender Employer/School Living at Home? Yes/No Family Title (Father/Mother, Brother/Sister, Aunt/Uncle, Etc.) Level of Education Contact Phone

2 Parent Information Host Parent 1 (Primary Contact Person) Name Occupation Job Title Employer Primary Mobile Phone Business Phone Fax Host Parent 2 Name Occupation Job Title Employer Primary Mobile Phone Business Phone Fax Residence and Community Residential Address Address State Home Phone Zip Code City Home Fax Mailing Address, leave blank if same as above Address State Zip Code Home Phone City Home Fax home. 1. Type of Home (e.g. townhome, single family, apartment, etc.) 2. (a). Is this residence part of a functioning business (e.g. farm, daycare, office, etc.) (b). If yes, are there employees who work at your home as part of your business? (c). If yes, please explain the levels of access the employees have to the living areas of your 3. Briefly describe your home (number of rooms, bedrooms, yard, etc.)

3 4. Will the student have his or her own bedroom? a. If not, who will share a room with the student? 5. Briefly describe the neighborhood you live in (Is it gated, do you have neighbors, etc.?) 6. Is your home in a: City? Suburb? Town? Village? Rural Area? 7. Population of your Community 8. Name of Nearest City Distance to Nearest City 9. Briefly describe your community School Distance from Home to Fredericksburg Academy: Miles Minutes How will the student get to school? FA Bus Car Other What, if any, family members will attend school with the student What, if any, family members are affiliated with the school as an employee Placement Criteria Would you feel comfortable hosting a student who follows a particular dietary restriction? (e.g. food allergies, Kosher, vegetarian, vegan, gluten-free, etc.)? Would you feel comfortable hosting a student who smokes? Does anyone in the family follow any dietary restrictions? If yes, please explain.

4 Do you expect the student to follow the above dietary restrictions? Please explain. Does anyone in your family smoke? Inside or outside of the house? Do you have any pets? Please list the type and number of pets. What is the primary language spoken at home? What other languages are spoken at home? What languages are known by family members, and with what fluency? Have you ever hosted with another exchange organization? If yes, which organization(s) and dates of hosting Has anyone in your family ever lived outside the U.S.A? Please specify who, which countries and for how long.

5 Has anyone in your family ever traveled outside the U.S.A? Briefly mention who, which countries and for how long. What is your religious affiliation, if any? How often do you participate in religious services or activities? If you attend religious services or activities do you expect the student to attend with your family? Would any member of the household have difficulty hosting a student whose religious beliefs were different of their own? Describe any special circumstances (eating habits, unusual work hours, parents who travel often, etc.) to which the student will need to adapt to in your family.

6 Part 2- Confidential Form Instructions: Please fill in all applicable fields. Please note that this information you disclose in this form will not be shared with your hosted student. Has anyone living in the home received professional counseling within the past five years? If yes, please describe the dates of the treatment, how the situation affects the family members everyday lives, and if the family member is currently in a stable condition. Does anyone in the home have a serious illness, chronic medical condition, or physical or mental disability, or take any medications for mental health conditions? If yes, give a brief description. Has any member of your household ever been charged with any crime? If yes, please give a brief explanation including date of charges, reason for charge, and outcome. Has anyone living in the home ever had his/her driver s license suspended or revoked? If yes please give brief explanation which gives date license was revoked, reason, and date of reinstatement.

7 Part 3- Host Family Description Why is your family interested in hosting an exchange student? Please indicate the major interests, hobbies and activities of members of your family. Include any sports or fitness activities, religious activities, volunteering, etc. Describe each member in the family (including yourself) in terms of personality, activities, achievements and interests, etc. Describe a typical weekday in your family. Describe a typical weekend in your home.

8 When you do something special on a weekend, what might you do? Describe any common family activities in a week or in the month. This can include: swim meets on Fridays, church on Sundays, monthly movie night, etc. Be specific about who attends and how often it occurs. How does your family celebrate birthdays? What specific things are your family traditions for birthdays? What other holiday traditions does your family celebrate or take part in? Describe the different holidays you celebrate and how you celebrate them. Be sure to mention any particular traditions for the holidays you celebrate (Hanukah, Christmas, Kwanzaa, Ramadan, Diwali, Easter, Thanksgiving, etc.).

9 Describe what is important to your family. What are your family values? What are some of your family s rules? Think about the unspoken rules or actions you might have as well. Are children required to check in with parents when they are going somewhere different; do you answer the phone if you are the closest? Does everyone sit and watch the news together after dinner? Describe your expectations regarding the responsibilities and behavior of the student while in your home (chores he or she will participate in, curfew, computer time, etc.). What personal expenses do you expect to be covered by the student? (e.g. shampoo, toothpaste)

10 Are there any upcoming family trips for which the student will be expected to contribute? When are these trips scheduled? How do you envision the student s involvement in your family? How do you hope to help ease the transition into your family? What things would you like to do over the year with your student? What special trips or excursions do you hope to make? What would you like to learn as a family about your student and his or her home country?

11 What are you most excited about? Part 4- Host Student Letter Please write and attach a letter to your student telling them about your family. Have each member write something about themselves and what they are excited for, and any other personal things or messages they would like to relay to the student. Be sure to talk about family responsibilities and things your family enjoys doing together. Also please send or attach some photos of you and your family for your student with captions describing the pictures. You can send the pictures to These pictures could be your family and you doing everyday activities, any pets, the home or the student s room, or anything else you would like to share with them before they arrive. Signature of Host Parent 1 Date Signature of Host Parent 2 Date There shall be no discrimination by the School in the selection of the Board of Trustees, the employment of personnel, in the admission of students, or in the administration of the School programming because of race, color, religion, national origin, sex, age, sexual orientation, or handicapped status in violation of existing state or federal law or regulations. Notice: Fredericksburg Academy reserves the right at all times to modify its admission requirements and to discontinue, modify, or change its educational programs when it determines that it is in the best interest of the school to do so. Fredericksburg Academy Office of Admission Academy Drive Fredericksburg, Virginia Fax:

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