Host Family Interview – Rocky Mountain Rotary Youth Exchange

Submit the Host Family Interview Form & Photos

If you have completed the host family interview, please submit this form to submit the information and photos automatically to your Country Contact.

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

Submit the information from the host family interview

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*
MM slash DD slash YYYY
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:*
- Less than $25,00
- $25,000-$35,000
- $35,000-$45,000
- $45,000-$55,000
- $55,000-$65,000
- $65,000-$75,000
- $75,000 and above
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*
Accepted file types: jpg, png, jpeg, Max. file size: 64 MB.
Photo of the kitchen*
Accepted file types: jpg, png, jpeg, Max. file size: 64 MB.
Photo of the student's bedroom*
Accepted file types: jpg, png, jpeg, Max. file size: 64 MB.
Photo of the student's bathroom*
Accepted file types: jpg, png, jpeg, Max. file size: 64 MB.
Photo of the family/living areas*
Accepted file types: jpg, png, jpeg, Max. file size: 64 MB.
Please add any additional photos here as well.
Drop files here or

Accepted file types: jpg, png, jpeg, Max. file size: 64 MB, Max. files: 2.

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Submit the Host Family Interview Form & Photos

Appendix B: Host Family Interview Results

Basic Family Information

Diet

High School Information

Community Information

Home Description

Family Activities

Photos