Breaking Bread
Local Host Application
Primary Host Information
Primary Host Information
First Name: *
Your answer
Last Name: *
Your answer
Gender: *
Your Age: *
Your answer
Email Address: *
This will be our main method of communication with you, so please be sure the address you provide is correct.
Your answer
Phone Number: *
Your answer
Home Address: *
Your answer
Field of Study or Occupation: *
Your answer
Please indicate your employer (if applicable): *
If not applicable, type "N/A"
Your answer
Affiliation with NC State University: *
Primary Host Information
Religion (Optional):
Your answer
Partnership Status *
Will anyone else be participating in the meal? *
(family members, friends, neighbors, roommates, etc.)
If married or partnered, please list the name, gender, and age of your partner below: *
If you are not married or partnered, and/or your partner will not be participating, please type "N/A"
Your answer
If you have children who will be participating, please list their names, genders, and ages below: *
If you do not have children who will be participating, please type "N/A"
Your answer
Other than partners and children, if anyone else will be participating, please list their names, genders, and relationships to you (i.e., friends, neighbors, other relatives, roommates, etc.): *
If no one else will be participating, please type "N/A"
Your answer
Additional Information
Who would you prefer to be matched with? (Mark all that apply) *
NOTE: Single hosts will be matched with persons of the same sex
Required
How many students/scholars are you willing to host? *
Please select 1,2,3,4, or list another specific number.
Are you comfortable cooking for dietary restrictions? *
Do you have pets in your home? *
If you have pets in your home, please indicate how many and what kind:
(e.g., "2 dogs and 1 cat")
Your answer
Are you willing to provide transportation to and from your home? *
Additional Information Continued
Please write a brief description of yourself (and other participants if applicable): *
(What is important to you, hobbies, interests, etc.)
Your answer
International Interest, Experience, Background, and Foreign Language Skills: *
(Foreign language skills are not required.)
Your answer
Community and Professional Affiliations: *
(Church, religious/civic groups, memberships, etc.)
Your answer
How did you hear about the Breaking Bread Program? *
If someone referred you to the program, please list their name(s).
Your answer
Personal Reference
Please provide information for one personal reference; this individual should be over the age of 18 and not a member of your family.
First and last name *
Your answer
Email address *
Your answer
Phone number (optional)
Your answer
Relationship to host *
Your answer
Term and Conditions
REQUIRED (Please read) *
Required
REQUIRED (Please read) *
Required
OPTIONAL - The Office of International Services (OIS) would like to update our promotional and marketing materials for the Breaking Bread Program using pictures of current Breaking Bread hosts and guests. If you would like to allow OIS to use your photo(s) for this purpose, please acknowledge your agreement to the following terms:
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