HOST FAMILY APPLICATION. Part A

Transcription

1 HOST FAMILY INFORMATION: Part A Host Mother First Name: Occupation: Last Name: Work Phone: Cell Phone: Host Father: First Name: Occupation: Last Name: Work Phone: Cell Phone: Home Address: Home Phone: City: State: Zip: Minors Living in the Home: Minors Not living in the Home: Other Adults Living in the Home:

2 Part A page II ARRIVAL DATE: Students typically arrive just prior to school starting, last week in August. When would you be able to take a student into your home? SMOKING: Does any member of your family smoke? Yes: No: If yes, who? TRANSPORTATION: Student will (check one) Walk Bus Other (please explain) Will transportation be available for extracurricular activities? Yes No

3 Part B FAMILY HISTORY: Are there health conditions (physical or mental) of any family member which may affect the placement of a student with your family? Yes: No: If Yes please explain: Does any family member have any sort of criminal record? Yes: No: If Yes please explain: Are there firearms in the home? Yes: No: If Yes is the firearm secured and in a safe place? Yes: No: REFERENCES: Please list 3 people, other than relatives, willing to be interviewed and to provide Sheridan Academy a written statement of your qualifications as a potential Host Family for an international student. Name: Address: City: State: Phone: Name: Address: City: State: Phone: Name: Address: City: State: Phone: Family and Community Life: Provide a list of the hobbies and interests of family members: Describe the type of activities for teenagers in your home and community: How did you decide to host an exchange student?

4 Part B page II Has the entire family discussed and agreed to hosting a student? Yes No If no, please explain: What does your family hope to learn from this experience? Describe how you would integrate the international student into your family. (EX: Sharing daily/weekly chores, participate in family activities, i.e.: outings, sporting events, religious services): RELIGIOUS PREFERENCES: Father: Mother Children Describe the family s religious involvement: (check one) Very Active Active Little Interest Do you expect the student to attend church with your family? Yes No If so, how frequently? Bi-weekly Weekly Monthly Would you accept a student of a different religion or who has no religious affiliation? Yes No

5 Part C HOME ENVIRONMENT: Do you feel that you can welcome an exchange student as a member of your family and not as a guest in your home? Yes No Do you have pets? Yes: No: If Yes: number, type, indoor or outdoor? Does anyone in your family have allergies? Yes: No: Would you accept a student with allergies? Yes: No: How do you plan to house the student?: Own room Shared room If shared, with whom: Name Age Sex: Can you provide a quiet place for your student to study? Yes No If No Please explain: HOSTING EXPERIENCE: Have you ever hosted an exchange student? Yes: No: If Yes, through what organization/agency? Was it a positive experience? Yes: No: Please describe. Do you have a preference for a male or female student? Yes: No: Preference: Do you have a Country preference? Yes: Preference: No:

6 Part D U.S. DEPARTMENT OF STATE REGULATIONS REQUIRE HOST FAMILIES TO COMPLETE A BACKGROUND CHECK. PLEASE READ THIS BEFORE YOU SIGN AND DATE THE COMPLETED APPLICATION. My/our initials on each line confirm that: 1. I/we gives permission for the Sheridan Academy Representative to do a visual tour of my/our home. 2. I/we understand I/We will be interviewed by a representative of the Sheridan Academy who will explained the responsibilities related in accepting an exchange student in my/our home for a school year/semester, this also includes the financial limits of our responsibility to the student. 3. I/we understand that the Sheridan Academy must follow certain federal and voluntary guidelines in the placement of students, which includes, but is not limited to: 1) home visits made by an ongoing contact with the student/host family assigned to work with the Sheridan Academy representatives. 4. I/we agree to cooperate with the Sheridan Academy s regulations and requirements regarding the exchange students. Should I/we have questions, I/we will talk first with our Sheridan Academy Representative. 5. I/we have been informed of Sheridan Academy s restrictions on student driving. I/we understand that a Sheridan Academy exchange student may not drive a car or other motorized vehicle during his/her exchange. The only exception is the student s participation in a school sponsored Driver s Education program. 6. I/we understand that the completion of this application is not a guarantee that a Sheridan Academy student will be placed in my/our home. 7. I/we understand a Background Check, including Drug Testing is required by the Sheridan Academy for approval as a host family. Host Parent Signature: Date: Host Parent Signature: Date: