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Host Family Application Form 2023
Thank you so much for your interest to be a host. Please fill out the application below.
Who is the first contact recruiter?
Melanie
Phyllis
Mimi
Others
If Others, please describe:
Which program(s) are you interested in?
Chiba Shoka High School: 7/14(Fri) - 7/27(Thu) 13 Nights
Parent 1 Name:
Parent 2 Name:
Address
City
State
Postal Code
Home phone #:
Parent 1 cell phone #:
Parent 1 email:
Parent 1 occupation:
Parent 1 work hrs:
Parent 2 cell phone #:
Parent 2 email:
Parent 2 occupation:
Parent 2 work hrs:
Who is the main contact person?
Parent 1
Parent 2
Home
Children *Please include exchange students you currently host
Child's Name:
Date of Birth:
Gender
Male
Female
Relationship
Son
Daughter
Int'l student
Living at home?
Yes
No
Child's Name:
Date of Birth:
Gender
Male
Female
Relationship
Son
Daughter
Int'l student
Living at home?
Yes
No
Child's Name:
Date of Birth:
Gender
Male
Female
Relationship
Son
Daughter
Int'l student
Living at home?
Yes
No
Child's Name:
Date of Birth:
Gender
Male
Female
Relationship
Son
Daughter
Int'l student
Living at home?
Yes
No
Residence type:
House
Apartment
Condo
Others
# of bedrooms:
Family hobbies:
Host student preference:
Boy
Girl
Either
Student's room will be:
Private
Shared
If shared, with whom?
Pets are:
Inside
Outside
If yes, what kinds?
Anybody has a serious chronic illness/ disability (please describe if any):
Anybody smokes?
No
Yes
Homeowner's insurance:
No
Yes
Policy #
Auto insurance:
No
Yes
Policy #
Anybody has a police record?
No
Yes
If Yes, please describe:
Signature
*
clear
Date:
*
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