Host Application Form

Thank you for beginning the host family 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 note that the Department of State requires that YFU USA complete a background check on all volunteers, host families and staff; your authorization will be requested during the application process. For any questions related to completing the application, call your local YFU representative or District Office at 1- 866-4-YFU-USA.

Parent #1 (Main Contact with YFU)

Full legal name required. If you do not have a middle name, please enter "none"

First Name:

Middle Name:

Last Name:

Last Name Used for Mailings:

Marital Status:

Single Parent Household?:

Gender:

Birth Date (mm/dd/yyyy):

Cell Phone Number (i.e. 240/235-2100):

Ethnicity:

Primary E-Mail Address:

For Regular Contact by YFU:

Secondary E-Mail Address:

For Alternate Contact by YFU:

Occupation:

Employer Name:

Employer City:

Employer State:

Work Phone Number (i.e. 240/235-2100):

Parent #2

Full legal name required. If you do not have a middle name, please enter 'none'

First Name:

Middle Name:

Last Name:

Gender:

Birth Date (mm/dd/yyyy):

Cell Phone Number (i.e. 240/235-2100):

Ethnicity:

Primary E-Mail Address:

For Regular Contact by YFU:

Secondary E-Mail Address:

For Alternate Contact by YFU:

Occupation:

Employer Name:

Employer City:

Employer State:

Work Phone Number (i.e. 240/235-2100):

Household

Street Address:

City:

State:

Zip Code:

Phone (i.e. 240/235-2100):

Is this a Landline?:

Best Time to Contact You:

How Did You Hear About YFU?:

Optional Information

YFU appreciates your providing the following information. It is for statistical use only and will not be used by YFU in making host family decisions.

Parent #1 - Highest Education Level Completed:

Parent #2 - Highest Education Level Completed:

Household Annual Income:

Community Population:

Time at Residence (years/months):

Additional Household Members

Please use this space to provide information on additional household members (i.e. children or other adults) and identify their relationship to your future exchange student. If any of the household members are 18 or older then please enter their full legal name (If they do not have a middle name, please enter 'none').

Household Member #1

First Name:

Middle Name:

Last Name:

Relationship to Parent(s):

Birth Date (mm/dd/yyyy):

Gender:

Grade in School (as of June 2008):

Does this Person Live at Home?:

Household Member #2

First Name:

Middle Name:

Last Name:

Relationship to Parent(s):

Birth Date (mm/dd/yyyy):

Gender:

Grade in School (as of June 2008):

Does this Person Live at Home?:

Household Member #3

First Name:

Middle Name:

Last Name:

Relationship to Parent(s):

Birth Date (mm/dd/yyyy):

Gender:

Grade in School (as of June 2008):

Does this Person Live at Home?:

Household Member #4

First Name:

Middle Name:

Last Name:

Relationship to Parent(s)

Birth Date (mm/dd/yyyy):

Gender:

Grade in School (as of June 2008):

Does this Person Live at Home?:

Household Member #5

First Name:

Middle Name:

Last Name:

Relationship to Parent(s)

Birth Date (mm/dd/yyyy):

Gender:

Grade in School (as of June 2008):

Does this Person Live at Home?:

Local High School

School Name:

Principal's Name:

Address:

City:

State:

Zip Code:

Phone Number (i.e. 240/235-2100):

Nearest Airport

Airport Name (commercial):

Local Newspaper

If selected, YFU would like celebrate your role as a YFU host family in the community. Please provide this information if you agree to have such an article submitted on your behalf.

Newspaper Name:

Address:

City:

State:

Zip Code:

Hosting Preference

Gender:

Length of Stay:

Family Interests

Please specify the interests and activities that are most important to your family members.

Arts:

Community:

Music:

Sports:

Other:

No. of Dogs in Household:

No. of Cats in Household:

No. of Other Pets in Household:

Type of Other Pets (if any):

Anyone in Household Smoke?:

Smoking Allowed in Household?:

Smoking Allowed Outside?:

Family Hosted Before?:

If Hosted, Which Organization/Year:

Religious Affiliation:

Religious Services Attendance:

Emergency Contacts

Please provide the names of two people who YFU may contact in an emergency if we are unable to reach an immediate family member.

Emergency Contact #1

Relationship to Family:

Name:

Street Address:

City:

State:

Zip Code:

Primary Phone (i.e. 240/235-2100):

Secondary Phone (i.e. 240/235-2100):

Work Phone (i.e. 240/235-2100):

E-Mail Address:

Emergency Contact #2

Relationship to Family:

Name:

Street Address:

City:

State:

Zip Code:

Primary Phone (i.e. 240/235-2100):

Secondary Phone (i.e. 240/235-2100):

Work Phone (i.e. 240/235-2100):

E-Mail Address:

References

Please list three people who have known your family for at least three years who are not YFU USA volunteers or employees. There should be one reference for each parent (two for Parent #1 if yours is a single parent household) and the third should be a family relative.

Reference #1

Reference For:

Name:

Street Address:

City:

State:

Zip Code:

Primary Phone (i.e. 240/235-2100):

Secondary Phone (i.e. 240/235-2100):

Work Phone (i.e. 240/235-2100):

E-Mail Address:

Reference #2

Reference For:

Name:

Street Address:

City:

State:

Zip Code:

Primary Phone (i.e. 240/235-2100):

Secondary Phone (i.e. 240/235-2100):

Work Phone (i.e. 240/235-2100):

E-Mail Address:

Family Reference

Relative Of:

Name:

Street Address:

City:

State:

Zip Code:

Primary Phone (i.e. 240/235-2100):

Secondary Phone (i.e. 240/235-2100):

Work Phone (i.e. 240/235-2100):

E-Mail Address (i.e. 240/235-2100):

Disclosures

Please explain the details for any 'Yes' responses in the "Additional Information" section.

To your knowledge, do you or any family member:

Have an arrest/conviction other than for parking/traffic violations?:

Have complaints filed with an agency concerning child neglect/abuse?:

Currently use illegal substances or have a drug/alcohol problem?:

Have any of the following events occurred within the last twelve months?

Divorce or re-marriage?:

Death of a spouse or child?:

Parent or child diagnosed with a serious illness?:

Additional Information

Please use this space to provide comments related to any of the above sections including Household Members, Hosting Preference and Disclosures. Or you may provide additional information about your household, lifestyle or schedule that you think YFU and/or an exchange student should know.

Comments:

Referrals

Teen in the household interested in being an exchange student?:

Is there anyone in the household interested in volunteering?:

Please provide the names of others who you think would like to hear about YFU opportunities, including hosting an exchange student, supporting an exchange student, or for teenagers, going on an international exchanges.

Referral #1-Name:

Phone Number (i.e. 240/235-2100)

Referral #2-Name:

Phone Number (i.e. 240/235-2100)

Online Host Family Application