Host Family Application

Host Family Application
Host Family's Name:*
Please select the program for which you are applying:*

Academic Year (August - June)Semester (August - December)Semester (January - June)Summer Program
If you are interested in hosting a summer student, please list the dates that you are available to host.*
What is your street address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your street address the same as your mailing address?*

YesNo
Please provide your mailing address below.*

Street Address/P.O. Box

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the home phone or primary phone number for your family?*
Type of Phone*

Please provide us with the name of someone we may contact in case of an emergency. (Must be someone that does NOT live in your home.)*

First NameLast Name
What is his/her relationship to you?*
Please provide us with his/her address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide his/her email address:*
example@example.com
What is his/her phone number?*

Are there any other persons living in your home? (i.e., friends, other relatives, foster children, another exchange student, etc.)*

YesNo

Which school would the student attend?*
School Phone Number:
School Fax Number:
School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the high school's approximate population?*
How far is the high school from your home?*
How will the student get to and from school?*

School busWalking or bicyclingRide with host parentRide with host sibling
Approximate school start date:

MonthDayYear
Date
Approximate school end date:

MonthDayYear
Date
Please provide a description of the high school (activities offered to students, campus description, student body, etc.).*
Please list some activities that are available to teenagers in your community.*

Have you ever hosted an international student before?*

YesNo
If so, when and for how long?*
What was the student's nationality?*
Through what organization did he/she come to the U.S.?*
What is the primary language spoken in your home?*
Is any member of your family fluent in another language?*

YesNo
Please explain.*
What is your family's combined annual income? (The income data collected will be used solely for the purposes of ensuring that the basic needs of the exchange student can be met, including three quality meals and transportation to and from school activities.)*
Does anyone in the home receive any kind of public assistance financial needs-based government subsidies for food or housing?*

YesNo
If so, please explain.*
Has your family ever had any contact with Child Protective Services in the past?

YesNo
If so, please explain.*
How did you learn about our cultural exchange program?*

Is your family willing to provide special transportation so that the student may participate in extracurricular activities either after school, in the evenings or on weekends?*

YesNo
Comments:
Do any of your children attend the same school in which the international student will be enrolled?*

YesNo
If so, please list any sports, clubs, activities, etc. that your children participate in at the school.
Does any member of your household work or volunteer for the high school in a coaching, teaching or administrative capacity?*

YesNo
If so, please explain.*
Has any member of your household had contact with a coach regarding the hosting of an exchange student with a particular athletic ability?

YesNo
If so, please describe the contact and name the sport.*
Give a brief description of the climate in your area. What is the appropriate clothing for the student to bring?*

If you have any other information that you would like to share with ARISE or have questions, please provide them below.
Name of Person Completing This Form:

Last Name
How are you related to the host family? (If this form is completed by someone other than a host parent, a copy must be given to the host family for their review. They will be required to sign a document verifying that all of the information contained in the application is correct and up-to-date.)

Host FatherHost MotherArea RepresentativeARISE's Main OfficeOther
By signing below, I confirm that the information provided in this application is true to the best of my ability.
Email of Host Parent Completing This Form:*
example@example.com
Signature of Host Parent Completing This Form:*

Clear
Date

MonthDayYear
Date
10810 N. Tatum Boulevard, Suite 102-845 Phoenix, AZ 85028 www.arise-usa.org

Toll-Free: 1-877-6-ARISE-6 Phone: (602) 641-9699 Email: info@arise-usa.org
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	Name	Gender	Date of Birth	Age	Relationship to Family	Does he/she live in your home full or part-time?
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