2017 BostonWise Host Family Survey
Information provided herein will only be used for students' placement.
How did you hear about BostonWise Exchange Program?
Your answer
Which school district do you live in?
Your answer
Contact Information
Home Address- Street
Your answer
Home Address- City
Your answer
Home Address-State
Your answer
Home Address- Zip Code
Your answer
What is the best time to contact you?
Your answer
Which number is the best to contact you?
Your answer
Host Parents
(Type "N/A." if no information provided)
Host Mother's First Name:
Your answer
Host Mother's Last Name:
Your answer
Date of Birth:
Your answer
Occupation:
Your answer
Work Schedule:
Your answer
Primary Email:
Your answer
Cell phone:
Your answer
Host Father's First Name:
Your answer
Host Father's Last Name:
Your answer
Date of Birth :
Your answer
Occupation:
Your answer
Work Schedule:
Your answer
Primary Email:
Your answer
Cell Phone:
Your answer
Other Residents in the Home
Resident 1
Name
Your answer
Gender
Date of Birth / Age
Your answer
Relationship
Your answer
Resident 2
Name
Your answer
Gender
Date of Birth / Age
Your answer
Relationship
Your answer
Occupation
Your answer
Resident 3
Name
Your answer
Gender
Date of Birth / Age
Your answer
Relationship
Your answer
Occupation
Your answer
Are there any smokers in your household?
Do you have firearms in your house? Are they being securely stored?
Your answer
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