Host Family Application

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Cincinnati-New Taipei Sister City
High School Student Exchange Program

Please complete all appropriate sections of this form.

We are applying to the Sister Cities of Cincinnati to host a foreign exchange student who will enter or entered the country as part of the New Taipei City, Taiwan Student Exchange program.

I would like to be considered for Hosting? *

Family Demographics

Section A - Host Family Profile and Environment

Primary Applicant's First Name *

Must be an Adult

Primary Applicant's Last Name *

Primary Date of Birth *

YYYY

U.S. Citizen (Primary)? *

Primary applicant

Yes

Other:

Email Address

Street Address *

City *

State *

Zip Code *

Telephone number (Home or Cell) *

Spouse's First Name

Spouse's Last Name

Spouse's Date of Birth

YYYY

U.S. Citizen (Spouse)?

Spouse Applicant

Yes

Other:

Clear selection

Spouse's Email Address

Primary Applicant's Employer *

Primary Applicant's Position *

Primary Business Phone Number *

Spouse's Employer

Spouse's Position

Spouse's Business Phone Number

List First Child

Full Name, Gender, Date of Birth

List Second Child

Full Name, Gender, Date of Birth

List Third Child

Full Name, Gender, Date of Birth

List Fourth Child

Full Name, Gender, Date of Birth

Please list additional children in the extra fields at the end if needed.

Check which Children Live at Home

Child 1

Child 2

Child 3

Child 4

Other:

List Other Adults Residing in Your Home (Name,Gender, DOB, Relationship)?

Please Indicate if any of these are present in your home?

Smoking

Pets (Indicate which below)

Other:

Please Indicate if any of these are present in your home?

Select the box if the answer is "Yes"! List pets in the next field.

Smoking

Pets (Indicate which below)

Other:

List pets here!

Host Home Profile

Host Family, describe each member of your household (e.g. level of education, profession, interests, community involvement)

Use additional spaces available at the end of this is not enough space.

Primary Applicant Profile

Spouse Applicant Profile

1st Child

2nd Child or Other Adult

3rd Child or Other Adult

4th Child or Other Adult

5th Child or Other Adult

Describe the type of home: *

Single Family

Multi-Unit Apartment

Duplex

Mobile Home

Condominium

Other:

Number of Rooms *

Number of Bedrooms *

Number of Bathrooms *

Will Exchange Student Share a Bedroom? *

If Yes, Select "Other" and say with whom?

Yes

Other:

Describe the room where the exchange student will stay?

Large/Small, Loft, Basement, Guest House, Furnishings, etc.?

Describe any amenities/areas that the student will have access to:

(Desk, Laundry, Kitchen, etc.)

Describe any amenities/areas that the student will NOT have access to:

(Desk, Laundry, Kitchen, Bedrooms, Offices, Garage, etc.)

Is the residence part of a functioning business? (ex: daycare, farm)

If Yes, describe [business and/or use] in the following Paragraph.

Yes

Clear selection

Describe Business.

What type of products are kept/manufactured/sold there? Are there any dangerous chemicals used/stored on the premises? etc.

Do any of the Residents have a Physical or Mental Disability?

If yes, please explain in the next paragraph.

Yes

Clear selection

Describe Disability or Disabilities.

To determine potential risk or burden to the Host Family.

Dietary Considerations

Would you accept a Student who.....? Select if "Yes".

Had Dietary Restrictions?

Were Vegan or Vegetarian?

Could not eat Red Meat?

Special Dietary needs? i.e. no fat, boiled food only, etc.

Could you provide 3 meals a day if needed?

Yes

Clear selection

Section B - Affiliations Community and Activities

Religious Affiliation:

What is your family’s religious affiliation/denomination/congregation?

How often do you attend religious services?

Do you expect the student to attend religious services with your family*?

*Students cannot be required to attend religious services. However, as part of the exchange, they are encouraged to experience this facet of U.S. culture at their discretion.

Yes

Sometimes

Would you feel comfortable hosting a student who attended services other than your own or did not attend religious services? Yes

Yes

Probably

Family Activities:

Language spoken in Home? *

Please describe activities and/or sports each family members participate in: (ex: Camping, Hiking, Dance, Crafts, Debate, Drama, Art, Music, Reading, Soccer, Baseball, Horseback riding, etc.)

Describe your expectations regarding the responsibilities and behavior of the student while in your home. (ex: Homework, Household chores, Curfew (school night and weekend),Smoking, Computer/Internet/E-Mail)

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

How did you learn about being a host family?

Section C - School and Comminity

High School Profile:

Local High School?

Approximate size of the school student body:

If known.

Approximate distance of school from the host family’s home:

In miles.

Approximately how far is it to the school?

When does school start?

School website?

If known!

How will the exchange student get to the school? *

School Bus

Metro Bus

Driven by Parent

Driven by Student/Child

Student Carpool

Paid Taxi

Walk

Other:

Would special transportation be available for extracurricular activities after school, on weekends or in the evenings?

Yes

Clear selection

Which of the host family’s children, if any, presently attend this school?

If any.

If applicable, list sports/clubs/activities, if any, the host 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? *

If so, what is their position? (Enter in the next question)

Yes

School Position?

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

If yes, please explain below.

Yes

Clear selection

Explain the nature of the contact!

If yes, please describe the contact and sport? What was discussed? What was the outcome?

Community Profile:

In what type of community does the host family live (ex: Urban, Suburban, Rural, Farm, etc.)?

Population of community?

Nearest Major City (Distance and population):

If your city is not a major city.

Nearest Airport (Distance)?

City or town Web site?

If known.

Briefly describe your neighborhood and community:

What points of interest are near the area (parks, museums, historical sites)?

Areas in or near your neighborhood to be avoided?

Please list and tell why?

Section C - Preferences and Experiences

We would prefer to host a

Boy

Girl

Either

Clear selection

Have any family members lived or traveled abroad?

Yes

Clear selection

If Yes, then where?

Have you hosted an exchange student before?

Yes

Clear selection

If Yes, then when?

YYYY

For what exchange program? Country?

Is the student you plan on hosting related to you or anyone in the house?

Yes

Clear selection

Will you be willing to host more than one exchange student in your home at the same time?

Yes

Clear selection

Does anyone residing in your home receive any kind of public assistance?

Yes

Clear selection

If Yes, please explain.

WIC, Social Security, Disability Payments, etc.

Any driving violations or accidents?

Other than parking tickets.

Yes

Clear selection

If Yes, please explain.

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

Also indicate dates(s) of crime(s) and in which country and state each took place.

Yes

Clear selection

If Yes, please explain!

References

Please list two personal references (including their addresses and phone numbers) Do Not use relatives. *

Name, Address, Relationship, Contact information (phone #)

Clear form

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