Primary Contact

First Name:  

Last Name:  

Home Phone:  

Cell Phone:  

Work Phone:  

Address:  

City:  

State:   

Zip Code:  

Email Address:  

Occupation:  

Family Members

Home Environment

List any household pets. Please indicate what kind and how many (cat, dog, etc.)
 

Does anyone in your household smoke? --Select-- Yes No  

What is your religious affiliation? (optional, may be considered in matching with student indicating preference)  

List activities and hobbies your family members enjoy:
 

Student Characteristic Preferences

Gender Preference:  --Select-- Male Female No Preference  

Smoking Preference: --Select-- Smoker Non-Smoker No Preference  

Student Status Preference: --Select-- Undergraduate Graduate No Preference  

Please list any preferences or objections to the student's religious affiliation:  

Other information

It is recommended that families meet with their student a minimum of twice a semester. How frequently do you plan to meet with your student (i.e. once a week, bi-monthly, monthly, etc.)?
 

Please list any other information you feel is relevant or important in the matching of your student.
 

List two references, other than family (i.e. civic leader, neighbor, politician, teacher)

May International Student Services maintain your name and address in our Host Family Directory? --Select-- Yes No  

Would you be interested in hosting a student short term (a few weeks) in your home? --Select-- Yes No