Host Family Application

The purpose of the Host Family program is (1) to assist the student in the process of adapting to U.S. culture, (2) to provide the student with adequate room and board, (3) to help the student successfully achieve their academic and personal goals, and (4) to develop a greater sense of cultural appreciation.

Fields marked * are required.

I am applying to provide*

Temporary Housing Upon Arrival (2-5 days)
Special Short-term Program (2-4 weeks)
Long-term Stay (2 + term)

How many students can you accommodate?*

General Information

Applicant's Last Name*

Applicant's First Name*

Spouse's First Name

Spouse's Last Name

Title*

Martial Status*

Address*

City*

State*

Zip*

Phone Number*

Length of Time in Community*

(If less than 1 year, please list previous address below.)

Previous Address

Previous City

Previous State

Previous Zip

E-mail

Cell Phone

Please list names of all persons in the immediate family

Name	Age	Gender	Living at Home	Relationship
		M F	Y N

Will there be anyone else staying in your home during the student's stay?* Yes No

Applicant's Occupation Information

Applicant's Occupation/Position*

Name of Employer*

Address of Employer*

City, State, Zip*

Work Telephone*

Best Time to Call*

AM PM

Best Place to Call*

Home Work

Spouse's Occupation Information

Spouses's Occupation/Position

Name of Employer

Address of Employer

City, State, Zip

Work Telephone

Best Time to Call

AM PM

Best Place to Call

Home Work

How did you learn about the host family program?*

Host Family Information
Has your family ever hosted an international student before?*
Yes No
Have any of your family members had experiences with other cultures?*
Yes No
Do any family members speak a foreign language?*
Yes No

Does anyone in your home smoke?*
Yes No

Would you be willing to host a student who smokes?*
Yes No Maybe

Does anyone in your home drink alcoholic beverages?*
Yes No

Would you be willing to host a student who drinks socially?*
Yes No

Are you willing to accommodate a student with dietary restrictions?*
Yes No

What is your family's religious preference/denomination/
congregation?*

How often do you attend religious services?*

Do you expect the student to attend religious services with your family?*

Yes No

Would you feel comfortable hosting a student who did not attend religious services or who attended services other than your own?*
Yes No Uncertain

What pets, if any, do you have? Please specify if they are inside or outside of the house

What is the principal language spoken in your home?*

Which interests and activities are most important to your family members*

Art
Sports
Community
Music
Other

School Information
Are you able to provide the student transportation to campus regularly?
Yes No

Which, if any, of your family members attend or work at Bellevue University?

Host Family Background Has anyone in your family ever been arrested or convicted for any offense other than a minor traffic violation? *
Yes No

Do any family members have a psychological or physical disability?*
Yes No

Further Information
Please indicate your hosting preferences

Sex*

Male Female No Preference

Host Family References

Reference 1

Reference 2

Name*
Address*
City, State, Zip*
Telephone*
Relationship*
Number of Years Known*

Program Agreement

By hosting a student, I agree to

Make every effort to make the student feel welcome at home and become part of the family.

Encourage independence, but also provide support in adjusting to the US.

Treat the student with respect.

Understand and appreciate their culture.

Provide a safe and comfortable environment.

I/We hereby certify that the information given on the pages of the Host Family Application is true and complete to the best of my/our knowledge.*