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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