Host Family Application
Community College Host Family Application Please note that per Department of State protocol, YFU USA completes a background check on all volunteers, host families and staff; your authorization will be requested during the application process. The completion of this application does not confirm the placement of a YFU student in your home. This application is used together with an interview report to select host families. Please return the completed form to your college campus coordinator.
Household (please type or use a black ballpoint pen) PARENT #1 Full legal name required. If you do not have a middle name, please enter "none". First Male
Middle Female
Last
Birth Date (mm/dd/yyyy)
Ethnicity (optional)
This is the primary contact for YFU.
Does this person live at home?
Cell Phone
Primary Email
Secondary Email
Can YFU contact you through this email?
Occupation / Position
Name of Employer
City
State
Yes
No
Yes
No
Yes
No
Yes
No
Work Phone
PARENT #2 Full legal name required. If you do not have a middle name, please enter "none". First Male
Middle Female
Last
Birth Date (mm/dd/yyyy)
Ethnicity (optional)
This is the primary contact for YFU.
Does this person live at home?
Cell Phone
Primary Email
Secondary Email
Can YFU contact you through this email?
Occupation / Position
Name of Employer
City
State
Work Phone
HOUSEHOLD Marital Status:
Married
Is this a single person household?
Single Yes
Domestic Partner No
Divorced
Preferred name used for YFU mailings
Street Address City
State
Phone
Is this a landline?
Zip Code Yes
No
Best time to call?
Widowed
Host Family Application Page 2
Family Name:
Optional Information This information is for statistical use only and will not be used in making host family selections. How did you hear about YFU? Parent #1:
High school or less
College
Graduate/Professional
Technical
Parent #2:
High school or less
College
Graduate/Professional
Technical
Education Level:
Household Annual Income
Community population
less than $25,000
$25,000 - $50,000
$75,000 - $100,000
over $100,000
urban (50,000)
suburban (15,000 – 50,000)
rural (less than 2,500)
$50,000 - $75,000
small town (2,500 – 15,000)
How long have you lived there (years/months)?
Other Household Members Name:
First
Middle
Relationship to parent(s): Male Name:
Female First
Birth Date (mm/dd/yyyy) Grade in School (as of June 2010)
Name:
Female First
Name:
Female First
Grade in School (as of June 2010)
Name:
Female First
Female
Does this person live at home?
Yes
No
Yes
No
Yes
No
Yes
No
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Middle
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Middle
Relationship to parent(s): Male
No
Last
Middle
Relationship to parent(s): Male
Yes
Birth Date (mm/dd/yyyy)
Relationship to parent(s): Male
Does this person live at home?
Middle
Relationship to parent(s): Male
Last
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Other Information LOCAL AIRPORT: Name of nearest airport to your home with scheduled commercial service LOCAL NEWSPAPER: By providing this information you authorize YFU to notify them if your family is selected as a host family. Name
Street Address
City
State
Zip Code
Host Family Application Page 3
Family Name:
HOSTING PREFERENCE: Please indicate your preferences if any. Male
Female
Either
Length of stay:
School year
Semester
6 weeks or less
FAMILY INTERESTS: Please specify the interests and activities that are most important to your family members. Arts
Community
Music
Sports
Other
Please list the number of pets in your home.
Dogs
Cats
Does anyone in your family smoke inside the home?
Yes
No
Would you permit a student to smoke inside your home?
Yes
No
Other
Outside of your home?
Has your family hosted an exchange student for an academic semester or year before?
Yes
No
Yes
No
If yes, please indicate the years and with what organization. What is your family’s religious affiliation (if any)? How often does your family attend religious services?
more than once a week
weekly
occasionally
seldom
Emergency Contacts Two people who YFU may contact in an emergency if we are unable to reach an immediate family member. Emergency Contact #1 Name Street Address City
State
Zip Code
Primary Phone
Secondary Phone
Work Phone
Email
Emergency Contact #2 Name Street Address City
State
Zip Code
Primary Phone
Secondary Phone
Work Phone
Email
never
Host Family Application Page 4
Family Name:
References Please list three people willing to serve as a reference who have known your family for at least three years and who are not YFU USA volunteers or employees. One person should be a reference for host parent #1, the second should be a reference for host parent #2 (or a second reference for host parent #1 if this is a single person placement) and the third should be a relative. Reference for Parent #1 Name Street Address City
State
Zip
Primary Phone
Secondary Phone
Work Phone
Email
Reference for Parent #2 (or a second reference for host parent #1 if this is a single person placement) Name Street Address City
State
Zip
Primary Phone
Secondary Phone
Work Phone
Email
Reference who is a Relative Name Relation Street Address City
State
Primary Phone Work Phone
Zip Secondary Phone Email
Disclosures For any ‘Yes’ response, please explain the circumstances on the next page. To your knowledge, do you or any family member: Have an arrest or conviction record, other than for parking or minor traffic violations?
Yes
No
Have a complaint filed with an agency concerning child neglect or abuse?
Yes
No
Currently use illegal substances or have a drug/alcohol problem?
Yes
No
Yes
No
Have any of the following events occurred within the last twelve months? Divorce or re-marriage
Host Family Application Page 5
Family Name:
Death of a spouse or child
Yes
No
Parent or child diagnosed with a serious illness
Yes
No
Referrals Let us know of any family who would be good hosts to an international student or a teenager interested in study abroad. May we use your name in contacting them?
Yes
Teenager who might like to study abroad
No
Family that might like to host
Name
Telephone
Street Address
City
State
Teenager who might like to study abroad
Zip Family that might like to host
Name
Telephone
Street Address
City
State
Zip
Additional Information Do you have any comments related to above sections, including Other Household Members, Hosting Preference and Disclosures or additional information about your household, lifestyle or schedule that YFU and/or an exchange student should know?
We understand that by hosting an international student for the duration of his/her exchange, we will be providing a home away from home and we will treat him/her as a member of our family. We realize that we are responsible for providing our student his/her own bed and study space, three meals daily, access to the refrigerator/kitchen, laundry facilities, and some assistance with transportation arrangements. We also understand and accept that YFU USA, in making its host family selections and student placements, does not discriminate on the basis of race, color, national origin, religion, gender, or sexual orientation. Applicant Signature(s): Parent 1:__________________________________________________ Date: ________________
Parent 2: __________________________________________________ Date: ________________ Thank you for completing a Youth For Understanding Host Family Application. Please review carefully the information you have entered on this application and save a copy for your records.
Household (please type or use a black ballpoint pen) PARENT #1 Full legal name required. If you do not have a middle name, please enter "none". First Male
Middle Female
Last
Birth Date (mm/dd/yyyy)
Ethnicity (optional)
This is the primary contact for YFU.
Does this person live at home?
Cell Phone
Primary Email
Secondary Email
Can YFU contact you through this email?
Occupation / Position
Name of Employer
City
State
Yes
No
Yes
No
Yes
No
Yes
No
Work Phone
PARENT #2 Full legal name required. If you do not have a middle name, please enter "none". First Male
Middle Female
Last
Birth Date (mm/dd/yyyy)
Ethnicity (optional)
This is the primary contact for YFU.
Does this person live at home?
Cell Phone
Primary Email
Secondary Email
Can YFU contact you through this email?
Occupation / Position
Name of Employer
City
State
Work Phone
HOUSEHOLD Marital Status:
Married
Is this a single person household?
Single Yes
Domestic Partner No
Divorced
Preferred name used for YFU mailings
Street Address City
State
Phone
Is this a landline?
Zip Code Yes
No
Best time to call?
Widowed
Host Family Application Page 2
Family Name:
Optional Information This information is for statistical use only and will not be used in making host family selections. How did you hear about YFU? Parent #1:
High school or less
College
Graduate/Professional
Technical
Parent #2:
High school or less
College
Graduate/Professional
Technical
Education Level:
Household Annual Income
Community population
less than $25,000
$25,000 - $50,000
$75,000 - $100,000
over $100,000
urban (50,000)
suburban (15,000 – 50,000)
rural (less than 2,500)
$50,000 - $75,000
small town (2,500 – 15,000)
How long have you lived there (years/months)?
Other Household Members Name:
First
Middle
Relationship to parent(s): Male Name:
Female First
Birth Date (mm/dd/yyyy) Grade in School (as of June 2010)
Name:
Female First
Name:
Female First
Grade in School (as of June 2010)
Name:
Female First
Female
Does this person live at home?
Yes
No
Yes
No
Yes
No
Yes
No
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Middle
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Middle
Relationship to parent(s): Male
No
Last
Middle
Relationship to parent(s): Male
Yes
Birth Date (mm/dd/yyyy)
Relationship to parent(s): Male
Does this person live at home?
Middle
Relationship to parent(s): Male
Last
Last Birth Date (mm/dd/yyyy)
Grade in School (as of June 2010)
Does this person live at home?
Other Information LOCAL AIRPORT: Name of nearest airport to your home with scheduled commercial service LOCAL NEWSPAPER: By providing this information you authorize YFU to notify them if your family is selected as a host family. Name
Street Address
City
State
Zip Code
Host Family Application Page 3
Family Name:
HOSTING PREFERENCE: Please indicate your preferences if any. Male
Female
Either
Length of stay:
School year
Semester
6 weeks or less
FAMILY INTERESTS: Please specify the interests and activities that are most important to your family members. Arts
Community
Music
Sports
Other
Please list the number of pets in your home.
Dogs
Cats
Does anyone in your family smoke inside the home?
Yes
No
Would you permit a student to smoke inside your home?
Yes
No
Other
Outside of your home?
Has your family hosted an exchange student for an academic semester or year before?
Yes
No
Yes
No
If yes, please indicate the years and with what organization. What is your family’s religious affiliation (if any)? How often does your family attend religious services?
more than once a week
weekly
occasionally
seldom
Emergency Contacts Two people who YFU may contact in an emergency if we are unable to reach an immediate family member. Emergency Contact #1 Name Street Address City
State
Zip Code
Primary Phone
Secondary Phone
Work Phone
Emergency Contact #2 Name Street Address City
State
Zip Code
Primary Phone
Secondary Phone
Work Phone
never
Host Family Application Page 4
Family Name:
References Please list three people willing to serve as a reference who have known your family for at least three years and who are not YFU USA volunteers or employees. One person should be a reference for host parent #1, the second should be a reference for host parent #2 (or a second reference for host parent #1 if this is a single person placement) and the third should be a relative. Reference for Parent #1 Name Street Address City
State
Zip
Primary Phone
Secondary Phone
Work Phone
Reference for Parent #2 (or a second reference for host parent #1 if this is a single person placement) Name Street Address City
State
Zip
Primary Phone
Secondary Phone
Work Phone
Reference who is a Relative Name Relation Street Address City
State
Primary Phone Work Phone
Zip Secondary Phone Email
Disclosures For any ‘Yes’ response, please explain the circumstances on the next page. To your knowledge, do you or any family member: Have an arrest or conviction record, other than for parking or minor traffic violations?
Yes
No
Have a complaint filed with an agency concerning child neglect or abuse?
Yes
No
Currently use illegal substances or have a drug/alcohol problem?
Yes
No
Yes
No
Have any of the following events occurred within the last twelve months? Divorce or re-marriage
Host Family Application Page 5
Family Name:
Death of a spouse or child
Yes
No
Parent or child diagnosed with a serious illness
Yes
No
Referrals Let us know of any family who would be good hosts to an international student or a teenager interested in study abroad. May we use your name in contacting them?
Yes
Teenager who might like to study abroad
No
Family that might like to host
Name
Telephone
Street Address
City
State
Teenager who might like to study abroad
Zip Family that might like to host
Name
Telephone
Street Address
City
State
Zip
Additional Information Do you have any comments related to above sections, including Other Household Members, Hosting Preference and Disclosures or additional information about your household, lifestyle or schedule that YFU and/or an exchange student should know?
We understand that by hosting an international student for the duration of his/her exchange, we will be providing a home away from home and we will treat him/her as a member of our family. We realize that we are responsible for providing our student his/her own bed and study space, three meals daily, access to the refrigerator/kitchen, laundry facilities, and some assistance with transportation arrangements. We also understand and accept that YFU USA, in making its host family selections and student placements, does not discriminate on the basis of race, color, national origin, religion, gender, or sexual orientation. Applicant Signature(s): Parent 1:__________________________________________________ Date: ________________
Parent 2: __________________________________________________ Date: ________________ Thank you for completing a Youth For Understanding Host Family Application. Please review carefully the information you have entered on this application and save a copy for your records.
