Host Family Interview – Family – Rocky Mountain Rotary Youth Exchange

Spring/Summer 2023: We are revising the host family application process & migrating to a new system for the application, training, and background checks. We apologize for any duplicate steps during this updated! If you have hosted in the past, you might recognize these are the questions the YEO asked in person, we are now requesting you to submit this information to reduce the time needed for the in home interview from 2+ hours to something more reasonable.

We also understand this form is long & some of the questions are a bit strange. Of course you have running water!
But we still need to ask all the questions on this page as a J-1 Secondary School Sponsor with the US Department of State and as a certified Rotary International Youth Exchange District. Interested in the minutia of the J-1 Visa program? Check out the list of family questions in the federal register. Otherwise continue below to submit this information to your YEO.

Home Interview steps

Complete this form in advance of the in home interview with the YEO. This form will be automatically sent to the YEO, the Country Contact, and the district. At the end of the form, you will need to submit photos of your home (outside, kitchen, living room, the bedroom & bathroom the student will use).
Schedule the in home interview with the YEO.
Complete an in-home interview, all members of the family should be present, with the YEO. During the in home interview they will review your answers, and may need to ask some follow up questions. They will then submit the YEO Host Family Interview form.

Host family interview – Prospective Family

"*" indicates required fields

READ THIS FIRST

If you refresh this page, the text entered will be wiped out.

Please make sure all fields& all photos are complete before clicking submit.

When the form is submitted successfully, the page will reload & display a short 2 sentence thank you message. If you continue to see the form fields, the form has not been submitted & we do not have access to your answers.

When the form successfully submits, you will receive a confirmation email with the information listed below and links to the photos you upload. The YEO & country contact will be automatically be copied on that email.

Part 1

Your Name*

First Last

Your Email*

Student's home country*

Scheduled dated of home visit & interview*

MM slash DD slash YYYY

If this is not confirmed, please enter a potential date.

Youth Exchange Officer Name*

First Last

Youth Exchange Officer Email*

References

Provide 3 references who are not relatives & 1 relative who are familiar with your family.

Please contact your references & provide them the YEO’s name and phone number to let them know they will be reaching out. The YEO will need to speak with your references to finish the host family application process.

Reference 1*

First Last

Person that is not a relative or former employer that we may contact.

Reference 1 Phone*

Reference 1 Email*

Reference 1 Occupation*

Reference 2*

First Last

Person that is not a relative or former employer that we may contact.

Reference 2 Phone*

Reference 2 Email*

Reference 2 Occupation*

Reference 3*

First Last

Person that is not a relative or former employer that we may contact.

Reference 3 Phone*

Reference 3 Email*

Reference 3 Occupation*

Immediate Family Reference 1*

First Last

Immediate Relative over 18 years of age not living in your home that we may contact

Immediate Family Reference Phone 1*

Immediate Family Reference Email 1*

Immediate Family Reference Occupation*

Family Demographic Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Number of adults over 18 in the home*

How many adults live in your house?

Please include students home visiting from college, or family visiting over the holiday who will be staying overnight in the home.

List all adults by full name:*

Please let all adults first name last name, first name last name.

ex: Jane Doe, John Doe, Suzy Smith

Number of children under 18 in the home*

How many kids live in your house full or part time?

List all kids, ages, and relationshp*

Please let all kids first names

ex: Bob 7 stepson, Jennifer 13 daughter, Apple 18 months daughter.

If no kids in the home, list ‘n/a’.

List kids activities*

Please let all kids first names

ex: Bob swimming, Jennifer dance, Apple toddler

If no kids in the home, list ‘n/a’.

Is the residence the site of a functioning business?*

Yes

(e.g., daycare, farm, counseling office)

If there is a business is in the home, please describe/provide additional detail:*

Has any member of your household ever been charged with any crime?*

Yes

Household Pets?*

Yes

Number of Pets*

Type/Kind of Pets*

Financial Resources:*

Less than $25,000

$25,000-$35,000

$35,000-$45,000

$45,000-$55,000

$55,000-$65,000

$65,000-$75,000

$75,000 and above

The income data collected will be used solely for the purposes of determining that the basic needs of the exchange student can be met, including three quality meals and transportation to and from school activities. These income levels are from Appendix F to Part 62.25(j).

Describe if anyone residing in the home receives any kind of public assistance. (financial needs-based government subsidies for food or housing)*

If none, write ‘n/a’ above.

Identify those personal expenses expected to be covered by the student.*

Diet

Does anyone in the family follow any dietary restrictions?*

Yes

If yes, another textbox will show below for more context.

Please describe dietary restrictions below*

Do you expect the student to follow any dietary restrictions?*

Yes

Maybe

If yes, another textbox will show below for more context.

Please describe dietary restrictions expected of the student?*

Would you feel comfortable hosting a student who follows a particular dietary restriction (ex. Vegetarian, Vegan, etc.)?*

Yes

Maybe

Please describe additional questions or other details around the student's potential dietary concerns.*

Would the family provide three (3) square meals daily?*

Yes

Informational Questions

How will the student get to school?*

Walk, bike, school bus, city bus, car pool, etc.

Would the family provide special transportation for extracurricular activities after school or in the evenings, if required?*

Yes

Which, if any, of your family's children, presently attend the school in which the exchange visitor is enrolled?

If applicable list sports/clubs/activities, if any, your child(ren) participate(s) in at the school

Does any member of your household work for the high school in a coaching/teaching/or administrative capacity?*

Yes

Please list which household member is involved with the school & in what capacity:*

Has any member of your household had contact with a coach regarding the hosting of an exchange student with particular athletic ability?

Yes

If yes, please describe the contact and sport.*

Community Information

In what type of community do you live (e.g.: Urban, Suburban, Rural, Farm)*

Population of community*

Wikipedia, city website site, USAfact.org, etc.

Nearest Major City (Distance and population)*

Nearest Airport (Distance)*

City or town website*

Briefly describe your neighborhood and community:*

What points of interest are near your area (parks, museums, historical sites)?*

Areas in or near neighborhood to be avoided?*

Home Description

Describe your type of home (e.g., single family home, condominium, duplex, apartment, mobile home)*

You will need to upload photos of the following areas: host family home’s exterior and grounds, kitchen, student’s bedroom, student’s bathroom, and family and living areas at the end of the form.

Describe Primary Rooms and Bedrooms*

Number of Bathrooms*

Will the exchange student share a bedroom?*

Yes

If yes, with which household resident will they share?*

Describe the student's bedroom*

Describe amenities to which the student has access*

(eg community pool, gym, n/a)

Utilities: Heat*

gas forces air, radiant floor hearing, boiler, etc

Utilities: Water*

city water

well water

Other

If you do not have indoor water, please select other & describe in detail.

Family Activities

Language(s) spoken in home*

Please describe activities and/or sports each family member participates in. (e.g., camping, hiking, dance, crafts, debate, drama, art, music, reading, soccer, baseball, horseback riding)*

Describe your expectations regarding the responsibilities and behavior of the student while in your home. (e.g., homework, household chores, curfew (school night and weekend), access to refrigerator and food, drinking of alcoholic beverages, driving, smoking, computer/Internet/E-Mail)*

Would you be willing voluntarily to inform the exchange visitor in advance of any religious affiliations of household members?*

Yes

Would any member of the household have difficulty hosting a student whose religious beliefs were different from their own?

Yes

Note: A host family may want the exchange visitor to attend one or more religious services or programs with the family. The exchange visitor cannot be required to do so, but may decide to experience this facet of U.S. culture at his or her discretion.

How did the family learn about being a host family?*

Part 2: Photos

Photo of the home's exterior and grounds*

Max. file size: 100 MB.

Photo of the kitchen*

Max. file size: 100 MB.

Photo of the student's bedroom*

Max. file size: 100 MB.

Photo of the student's bathroom*

Max. file size: 100 MB.

Photo of the family/living areas*

Max. file size: 100 MB.

Please add up to 5 additional photos here as well.

Drop files here or

Max. file size: 100 MB, Max. files: 5.

These are not required. However if you want to include additional photos, please upload them here.