2012 HOST FAMILY INTERVIEW and MATCHING FORM

Student Name: Student Number: Student Arrival Date: July 18, Student Departure Date: July 28, 2012 2012 Arrival Date with Host Family: Departure Date with Host Family: Coordinator: Gina Phone Number: 267Email Address: Cacace 251-2847 compassusagina@gmail.com Supervisor: Catherine Phone Number: 303Email Address: Stone 929-2436 compasscatherine@gmail.com Notes: Program # DIP22-2012 Homestay Community: South Jersey Host Family Name: Phone Numbe r: Email Address: Street Address: City: Stat e: Zip:

Mailing Address (if different than street address) Previous Address (if less than 3 years at the above address) Host Father Legal DOB: Ag Occupation: MM/DD/YYYY Name: e:
*(first, middle, last name)

Work Phone: Cell Phone:

Host Mother Legal Name:

*(first, middle, maiden name)

DOB:
MM/DD/YYYY

Ag e:

Occupation:

Work Phone: Cell Phone:

Children In Residence
*(first, middle, last name)

Male/Fe male

DOB:
MM/DD/Y YYY

Age

Interests

Sleeping Arrangements

Own Room

Shared Room

If shared, with whom?

If there are no teenagers in the home, please explain how your student will interact with other kids their age:
Animals Family Interest s Sports Hobbies Art Bicycling Boating Cooking Crafts Golf Horse Riding Music Musical Instrumen ts Snow Sports Soccer Travel Video Games

Activitie s

Baseball Basketb all

Camping Compute rs Cat:

Dance Fishing

Movies Museum s Reptile:

Reading Skating

Swimmin g Tennis Other:

Religion Other

Family Dog: Pets Smoker in Host Family?

Return Host Family?

For internships only please indicate distance and travel time from host family to business and public transportation options and costs.

OFFICE USE ONLY Date

B/C

W/E

W/P

RA (group)

IH (track)

F1

F2

CH G

HF

2012 HOST FAMILY INTERVIEW and MATCHING FORM

Host Family Name: Program Number: DIP22-2012
Please write a short welcome note below to your student and let them know why you are interested in hosting. If possible, attach a picture of your family.

2012 HOST FAMILY INTERVIEW and MATCHING FORM

Host Family Name: Program Number: DIP22-2012 YES 1. If you own firearms, are you willing to keep them locked up during the students stay? 2. Are there or have there in the past 2 years, been any drug and or alcohol problems in the home? If yes please explain: 3. Have you or anyone in your home ever been accused of or convicted of Child Abuse, Domestic Violence or a felony? If yes please explain: 4. Please describe the sleeping quarters for the student. Please confirm that s/he will have his/her own bed. Please confirm that the room your student will be sleeping in has a window. If s/he is not sleeping in a standard bedroom, please explain. 5. Is anyone home during the day? Please explain. 6. Does your family have any medical conditions, such as allergies, that might impact a visitor in your home? If so, please explain. 7. Will there be a phone available in your home at all times in case your student needs to make an emergency phone call? If not please explain? 8. Is any language besides English regularly spoken in the home? If so, will only English be spoken while the student is in the home? Please, sign us up to receive the quarterly Compass USA newsletter Please Provide Two Local Personal References Name: Address: Phone: Email Address: Name: Address: Phone: Email Address:
4
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NO

Information on this form is for office use only and will not be shared with Clients or Students. * Please Note a general background check will be done on all members of the family 18 years of age and over. Please provide first, middle, last and maiden name, if applicable. In addition, your coordinator is required to make a personal visit to your home.

The above information is true and correct to the best of our knowledge and we agree to host a student for Compass USA from July 18th, 2012 to July 28th, 2012. Host Parent Signature_______________________________________ Date ___________________________ Host Parent Signature_______________________________________Date__________________

Questions: Contact Compass USA 303-466-4707 or 1-877328-1827