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TEAM KIRTLAND HOME AWAY FROM HOME
HOST FAMILY QUESTIONNAIRE
Primary Host Family Member's Name:
(Title, Last, First, MI)
*
Employer/Occupation:
*
Hometown:
*
Spouse's Name: (Title, Last, First, MI)
*
Employer/Occupation:
*
Hometown:
*
Other Host Family Members who reside at the host family address (all ages):
Name, Relationship to Primary Host Family Member, Age, Gender, Occupation
+
-
Street Address:
*
City:
*
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code:
*
E-Mail Address(es):
+
-
Work Phone Number:
*
Home Phone Number:
Cell Phone Number:
Emergency Contact Name:
+
-
Emergency Contact Phone:
+
-
Please check here if your contact information in box is releasable to airmen’s parents and base staff members.
Yes
Family's Ethnicity:
(please select one)
African American
Asian/Pacific Islander
Caucasian
Hispanic
Inter-Racial
Native American
No Answer
Other
Family's Religious Affiliation:
(please select one)
Agnostic/Atheist
Baptist
Buddhist
Catholic
Muslim
Jewish
Methodist
Mormon/LDS
Non-Denominational
Christian
Protestant
No Answer
Unknown
Other
Family's Interests: (please select all that apply)
Aviation
Baseball
Basketball
Bikes
Board games
Computer/Video Games
Cooking/Baking
Fishing/Hunting
Football
Golf
Horseback Riding
Musical Instruments
Racquetball
Swimming
Tennis
TV/Movies
Watching Sports
Watersports
Other
Other
Do you have the following in your home? (please select all that apply)
*
Cats
Dogs
Other Pets
Smokers
None of the Above
Do you have access to Kirtland AFB?
*
Yes
No
Preferred Method of Communication:
+
-
Do you use texting via cell phone?
*
Yes
No
Airmen Request
Gender Preference:
Male(s)
Female(s)
No Preference
No Preference
How many Airmen are you willing to host?
*
Are you willing to accept an Airman who smokes?
*
Yes
No
Describe your expectation of interaction with the Airman you host:
If you have the name of a specific Airman you would like to host, please list the Airman’s name (Last, First)
*
How did you hear about the Home Away From Home Program?
*
Any additional comments/desires: