Host Family Interview – Rocky Mountain Rotary Youth Exchange

Appendix B: Host Family Interview Results

To be completed by the host club Youth Exchange Officer, in person, as part of the host family interview. The host family volunteer application, including reference checks, this check list and a clear background check must be completed before giving the potential family the youth exchange student’s application and/or revealing personal information about the student. Completion of these items is necessary to meet US State Department guidelines.

Your Name*

First Last

Your Email*

Student potentially being placed in the home's Name*

First Last

Student's home country*

Potential Host Family's last name*

Date of home visit & interview*

Basic Family Information

Is the residence the site of a functioning business?*

Yes
No

(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
No

Household Pets?*

Yes
No

Number of Pets*

Type/Kind of Pets*

Financial Resources:*

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
No

Please describe dietary restrictions below*

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

Yes
No

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
No

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

Yes
No

High School Information

Name of the high school*

Please also indicate is the school is private, otherwise it will be assumed the school is public.

High School Address*

Street Address Address Line 2 City State ZIP Code

School Official Name*

First Last

School Official Phone*

School Official Email*

School Official Address*

Street Address Address Line 2 City State ZIP Code

Approximate size of the school student body*

Approximate distance between the school and your home*

Approximate start date of the school year*

How will the exchange student get to the school?*

(e.g. bus, carpool, walk)

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

Yes
No

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
No

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
No

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*

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
No

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, etc

Utilities: Running Water*

Yes
No

Utilities: Indoor Plumbing*

Yes
No

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
No

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

Yes
No

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?*

Photos

Photo of the home's exterior and grounds*

Photo of the kitchen*

Photo of the student's bedroom*

Photo of the student's bathroom*

Photo of the family/living areas*

Please add any additional photos here as well.

Drop files here or

Submit the Host Family Interview form & Photos

Please gather all the information & photos necessary prior to starting the form

Appendix B: Host Family Interview Results

Basic Family Information

Diet

High School Information

Community Information

Home Description

Family Activities

Photos