International Programs
Educational Services Building – 3rd Floor
Admissions and Advising Wing
Bellevue University
1000 Galvin Road South
Bellevue, Nebraska 68005
Bellevue University

Host Family Application
Phone: 402-557-7281
Fax: 402-557-5423
Email: international@bellevue.edu
Website: www.bellevue.edu
Click on International


The purpose of the Host Family in the program is (1) to assist the student in the process of adapting to U.S. culture while the student is achieving program and personal objectives and (2) to provide the student with adequate room and board.
 
Last Name:     First Name (Applicant):     First Name (Spouse):
 
Title:       Marital Status:
 
Address:     City:     State:     Zip:
 
Telephone:   ()     Length of Time in Community:   (If less than 1 year, please list previous address below.)
 
Previous Address:     City:     State:     Zip:    
 
Email Address:     Cell Phone: ()

Please list names of all persons in the immediate family
(including host parents)
Age Sex Living at Home Relationship
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N
M  F Y  N

Will there be others staying in your home during the student's stay? Y  N       If yes, who?

Applicant's Occupation/Position Spouse's Occupation/Position
Name of Employer Name of Employer
Address of Employer Address of Employer
City, State, Zip City, State, Zip
Work Telephone () Work Telephone ()
Best Time/Place to Call am  pm Home  Work Best Time/Place to Call am  pm Home  Work


How did you learn about the Host Family Program?

Another host family     Neighbor/friend     Radio     Newspaper ad     Another international student       BU website

Other (please specify)
 
Host Family Information
1. Why does your family want to host an international student?
 
2. Please write a few sentences here to explain how your student will benefit from living in your home:
 
3. What are your perceptions of international students and their needs?
 
4. Has your family ever hosted an international student before?     Yes  No
If yes, when?   How long did the student live with your family?
 
5. Have any of your family members had experiences with other cultures?     Yes  No
If yes, please list:
 
6. Do any family members speak a foreign language?     Yes  No
If yes, please explain:
 
7. Does anyone in your home smoke?     Yes  No  Occasionally
 
8. Would you be willing to host a student who smokes?     Yes  No  Maybe
Which specific restrictions, if any, would you put on the student’s smoking habits while in your home?
 
9. Does anyone in your home drink alcoholic beverages?     Yes  No
If so, how often?     Rarely  Occasionally  Regularly
 
10. Would you be willing to host a student who drinks socially?     Yes  No
 
11. What is your family’s religious preference/denomination/congregation?    
 
12. How often do you attend religious services?     More than once a week  Weekly  Occasionally  Never
 
13. Do you expect the student to attend religious services with your family?     Yes  No
 
14. Would you feel comfortable hosting a student who did not attend religious services or who attended services other than your own?
Yes  No  Uncertain
Comments:
 
15. What pets, if any, do you have? Please specify if they are inside or outside of the house:
 
16. What is the principal language spoken in your home?
 
17. Which interests and activities are most important to your family members:     Art  Sports  Community

Music (please specify)  Other
 
School Information
1. How will the student get to school?
 
2. Which, if any, of your family members attend or work at Bellevue University?
 
Host Family Background
1. Has anyone in your family ever been arrested or convicted for any offense other than a minor traffic violation?     Yes  No
If yes, please explain:
 
2. Do any family members have a psychological or physical disability?     Yes  No
If yes, how might this disability influence the placement of an international student with your family?
 
Further Information
Please indicate your hosting preferences (if any):

Sex:   Male  Female

Length of Stay:   academic year  temporary housing upon arrival only
 

Please give two (2) references whom we may contact. These references can be work associates, friends, school officials, etc. Relatives will not be considered as references. All information that we receive on the reference forms is kept strictly confidential.

Host Family References

Reference #1 Reference #2
Name
Address
City, State, Zip
Telephone
Relationship
Number of Years

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.