Cultural Academic Student Exchange
HOST FAMILY APPLICATIONThis is only a preliminary application.
Family Information

Last Name:


Fathers First Name: Occupation:
Work Phone: Ext. Date of Birth: (mm/dd/yy)


Mothers First Name: Occupation:
Work Phone: Ext. Date of Birth: (mm/dd/yy)


Address1: Address2:
City: State: Zip: -
Phone (H): Fax :
Email:

What is the most convenient time and phone number to contact you at? 

Children's Information - List each child:
Name Age Sex Living at home?
Male   Female Yes   No
Male   Female Yes   No
Male   Female Yes   No
Male   Female Yes   No
Male   Female Yes   No
Male   Female Yes   No


Household Information

List any pets: Where do pets live? Indoors   Outdoors

Does anyone smoke?: Father   Mother   Child
Would you accept a student who smokes? Yes   No


Will student share a room (With teenager only)? Yes   No
If yes, with whom:


Has ANYONE in your immediate family ever been convicted of any offense other than a minor traffic violation?
Yes   No
If yes, please explain:


School Information:

Name of School Student Will Attend:
Street:
City: State: Zip: -
School's Phone Number:

What is your general opinion of the high school the student will attend?


Distance of school from home:
Less than 1 Mile
1-5 Miles
5-10 Miles
10-15 Miles
15-20 Miles
Greater than 20 miles

Method of transportation to school:
Family member drives
School bus
Public Transportation
Walk
Bike
Car Pool


Misc. Information

Closet airport city: Airport code:


Family's religious preference:
Do you attend regularly? Yes No
If yes, do you expect the student to attend? Yes No

Relative (not living at home) or friend to contact in case of emergency:
Street:
City: State: Zip: -
Phone: Relationship:

Does anyone play a musical instrument? Yes No
If yes, which instrument:

What are the interests and activities enjoyed by the family?

What are the household duties of the children?


What household duties would you expect of your student?


Which best describes your neighborhood:

How far from public transportation?
No public transportation
Less than 1 Mile
1-5 Miles
5-10 Miles
10-15 Miles
15-20 Miles
Greater than 20 miles

How did you hear about C.A.S.E.?
Area Rep
Church
Friend
Internet
Newspaper
Radio
School
Television

Why did your family decide to host a student?


If you are chosen as a host family, do you feel your family could welcome your student
as a family member and not as a guest? Yes No


I agree to supply three letters of reference from business and personal sources. After references and application are checked, if our family is chosen to be a host family, I agree to uphold all C.A.S.E. rules and regulations and will abide by all decisions made by C.A.S.E. officials.