Preferred Phone #1 *

(###)

###

####

Preferred Phone #2

(###)

###

####

Number of bathrooms available to visiting students

1

2

3+

Maximum number of students your are willing to host *

minimum of 3 is required. If you have a preferred number, but would be willing to take more if needed, please put in "additional information" at the end.

3

4

5

6

7+

Which student gender do you prefer to host?

Note: if there are high school aged children in the home, we will match the gender and general age range to the oldest for homestay placements.

No preference

Female

Male

Can you accomodate a guest with any of the following dietary needs/restrictions?

Select all that apply

Diabetic

Gluten-free

Vegan

Vegetarian

Can you accomodate a guest who uses a wheelchair?

Yes

No

Does your family have any indoor pets?

Cats

Dogs

Reptiles

Other (please specify below)

Volunteer Driver #1 DL Expiration Date

MM

DD

YYYY

Volunteer Driver #1 Date of Birth

MM

DD

YYYY

Volunteer Driver #2 DL Expiration Date

MM

DD

YYYY

Volunteer Driver #2 Date of Birth

MM

DD

YYYY