Name: (Title, Last, First, MI) *

Unit: *

Rank: *

Date Of Birth

Age: *

Month *

Day *

Gender: *

Hometown: *

Street Address: *

City: *

State: *

Zip Code: *

Email Address(es):

+-

Home Phone Number

Cell Phone Number

Work Phone Number *

Emergency Contact Name :

+-

Emergency Contact Phone:

+-

Please check here if your contact information in box is releasable to base staff members.

Yes

Ethnicity: (please select one) *

Religious Affiliation: (please select one)

Your Interests: (please select all that apply)

Are You A Smoker: *

Yes

No

Preferred Method of Communication: *

Do you use texting via cell phone?

Yes

No

Do you have transportation?

Yes

No

HOST FAMILY REQUEST

Do you prefer a Host Family with more than one Airman?

Yes

No

Do you prefer a Host Family with children under 18?

Yes

No

Do you prefer a Host Family with any of the following?

Describe your expectation of interaction with Host Family:

If you have the name of a Host Family you would like to be sponsored by, please list a Host Family’s member’s first and last names:

How did you hear about the Home Away From Home Program? *

Any additional comments/desires: