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Contact Information |
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Name (First/Last): |
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Address: |
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* City:
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State: |
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Zip/Postal Code: |
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Home Phone: |
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Work Phone: |
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Email Address: |
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Family Information |
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Family Type: |
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Marital Status:
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Children residing at home: |
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If yes, please list names and ages: |
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What
pets do you have at home?
(hold
down the ctrl button to
select multiple values)
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If other: |
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Does a member of your family smoke? |
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How did your family hear about P.I.E.?
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If other: |
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Has your family hosted an exchange student before?
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If yes, what length of stay? |
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Has anyone in your family been convicted of a felony? |
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If you answered yes to the felony question, please provide an explanation
below:
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Community Information |
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In what type of community does you family live? |
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What is the name of the public high school closest to your home? |
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How far is your home from the nearest High School? |
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How far is your home from public transportation? |
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What method of transportation will student use for school?
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Hosting Particulars |
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What
chores will the student be expected to
participate in?:
(hold
down the ctrl button to
select multiple values)
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Will the student share a room? |
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Will the student be allowed to smoke?
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Is your family willing to accept? |
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Nationality
preference:
(hold
down the ctrl button to
select multiple values)
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If other: |
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Length of program your family is interested in hosting:
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Sports, Hobbies and Musical Interests |
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Family
sports interests include:
(hold
down the ctrl button to
select multiple values)
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Family
hobbies include:
(hold
down the ctrl button to
select multiple values)
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Types
of music enjoyed in family:
(hold
down the ctrl button to
select multiple values)
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Instruments
played in family:
(hold
down the ctrl button to
select multiple values)
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Referrals |
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Can you suggest other families in your area who might be interested in hosting? |
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Can you recommend someone in your area who might be interested in receiving
literature on becoming a P.I.E. Area Representative?
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Do you have a son or daughter interested in participating in an outbound exchange
program? |
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