Host Family Application

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
Your answer
Primary Applicant's Last Name *
Your answer
Primary Date of Birth *
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U.S. Citizen (Primary)? *
Primary applicant
Email Address
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Telephone number (Home or Cell) *
Your answer
Spouse's First Name
Your answer
Spouse's Last Name
Your answer
Spouse's Date of Birth
MM
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U.S. Citizen (Spouse)?
Spouse Applicant
Spouse's Email Address
Your answer
Primary Applicant's Employer *
Your answer
Primary Applicant's Position *
Your answer
Primary Business Phone Number *
Your answer
Spouse's Employer
Your answer
Spouse's Position
Your answer
Spouse's Business Phone Number
Your answer
List First Child
Full Name, Gender, Date of Birth
Your answer
List Second Child
Full Name, Gender, Date of Birth
Your answer
List Third Child
Full Name, Gender, Date of Birth
Your answer
List Fourth Child
Full Name, Gender, Date of Birth
Your answer
Please list additional children in the extra fields at the end if needed.
Check which Children Live at Home
List Other Adults Residing in Your Home (Name,Gender, DOB, Relationship)?
Your answer
Please Indicate if any of these are present in your home?
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.
List pets here!
Your answer
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
Your answer
Spouse Applicant Profile
Your answer
1st Child
Your answer
2nd Child or Other Adult
Your answer
3rd Child or Other Adult
Your answer
4th Child or Other Adult
Your answer
5th Child or Other Adult
Your answer
Describe the type of home: *
Number of Rooms *
Number of Bedrooms *
Number of Bathrooms *
Will Exchange Student Share a Bedroom? *
If Yes, Select "Other" and say with whom?
Describe the room where the exchange student will stay?
Large/Small, Loft, Basement, Guest House, Furnishings, etc.?
Your answer
Describe any amenities/areas that the student will have access to:
(Desk, Laundry, Kitchen, etc.)
Your answer
Describe any amenities/areas that the student will NOT have access to:
(Desk, Laundry, Kitchen, Bedrooms, Offices, Garage, etc.)
Your answer
Is the residence part of a functioning business? (ex: daycare, farm)
If Yes, describe [business and/or use] in the following Paragraph.
Describe Business.
What type of products are kept/manufactured/sold there? Are there any dangerous chemicals used/stored on the premises? etc.
Your answer
Do any of the Residents have a Physical or Mental Disability?
If yes, please explain in the next paragraph.
Describe Disability or Disabilities.
To determine potential risk or burden to the Host Family.
Your answer
Dietary Considerations
Would you accept a Student who.....? Select if "Yes".
Could you provide 3 meals a day if needed?
Section B - Affiliations Community and Activities
Religious Affiliation:
What is your family’s religious affiliation/denomination/congregation?
Your answer
How often do you attend religious services?
Your answer
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.
Would you feel comfortable hosting a student who attended services other than your own or did not attend religious services? Yes
Family Activities:
Language spoken in Home? *
Your answer
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.)
Your answer
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)
Your answer
Identify those personal expenses expected to be covered by the student.
Your answer
How did you learn about being a host family?
Your answer
Section C - School and Comminity
High School Profile:
Local High School?
Your answer
Approximate size of the school student body:
If known.
Your answer
Approximate distance of school from the host family’s home:
In miles.
Your answer
Approximately how far is it to the school?
Your answer
When does school start?
Your answer
School website?
If known!
Your answer
How will the exchange student get to the school? *
Would special transportation be available for extracurricular activities after school, on weekends or in the evenings?
Which of the host family’s children, if any, presently attend this school?
If any.
Your answer
If applicable, list sports/clubs/activities, if any, the host child(ren) participate(s) in at the school:
Your answer
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)
School Position?
Your answer
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.
Explain the nature of the contact!
If yes, please describe the contact and sport? What was discussed? What was the outcome?
Your answer
Community Profile:
In what type of community does the host family live (ex: Urban, Suburban, Rural, Farm, etc.)?
Your answer
Population of community?
Your answer
Nearest Major City (Distance and population):
If your city is not a major city.
Your answer
Nearest Airport (Distance)?
Your answer
City or town Web site?
If known.
Your answer
Briefly describe your neighborhood and community:
Your answer
What points of interest are near the area (parks, museums, historical sites)?
Your answer
Areas in or near your neighborhood to be avoided?
Please list and tell why?
Your answer
Section C - Preferences and Experiences
We would prefer to host a
Have any family members lived or traveled abroad?
If Yes, then where?
Your answer
Have you hosted an exchange student before?
If Yes, then when?
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For what exchange program? Country?
Your answer
Is the student you plan on hosting related to you or anyone in the house?
Will you be willing to host more than one exchange student in your home at the same time?
Does anyone residing in your home receive any kind of public assistance?
If Yes, please explain.
WIC, Social Security, Disability Payments, etc.
Your answer
Any driving violations or accidents?
Other than parking tickets.
If Yes, please explain.
Your answer
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.
If Yes, please explain!
Your answer
References
Please list two personal references (including their addresses and phone numbers) Do Not use relatives. *
Name, Address, Relationship, Contact information (phone #)
Your answer
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