International Exchange Programs States’ 4-H 2014 SUMMER INBOUND HOST FAMILY APPLICATION If possible, please fill out the online version of this form instead of a paper version. The form is available on International website: () the States’ 4-H Print neatly or type HOST FAMILY INFORMATION (FOR 4-H OFFICE USE ONLY) FAMILY NAME ORGANIZATION STREET ADDRESS NAME CITY STATE ZIP ID CODE COUNTY FAX DATE of BIRTH GENDER AGE MAILING ADDRESS (if different) Chaperone hosting dates HOME PHONE HOST SIBLING CELL HOST SIBLING EMAIL ADULT # 1 NAME CELL PHONE Relationship to BIRTHDATE Delegate (eg host mom) (Optional) EMAIL: HOBBIES/INTERESTS/ PERSONALITY WORK PHONE EMPLOYER OCCUPATION ADULT # 2 NAME CELL PHONE Relationship to BIRTHDATE (eg host mom) (Optional) Delegate EMAIL HOBBIES/INTERESTS/PERSONALITY WORK PHONE EMPLOYER OCCUPATION EMERGENCY CONTACT DAY PHONE RELATIONSHIP OTHER FAMILY MEMBERS AND REGULAR OVERNIGHT ADULT GUESTS IN HOME to the left of the host sibling.)* (Place an “X” AGE (as of NAME GENDER BIRTHDATE GRADE Hobbies/Interests/Personality “X” 7/21/14) *If needed there is additional space on page 2 Why does your family want to host? Family interests during the summer: What languages are spoken in your home? Do you have any indoor pets? Yes No If yes, what animals & how many? Farm and/or Outdoor Animals: Type of Community: Urban Suburban Small Town Rural Non-Farm Farm Ranch # of acres and type of crop if applicable: Optional: What is your if any? family’s religious affiliation, Optional: How often do you attend religious services? Are there any physical, developmental or psychological health conditions in your family of which a delegate would need to be aware (ex: physical disability, Down syndrome, hearing loss, ADD/ADHD, Autism, etc.)? If both parents work outside the home, who will assume responsibility when both parents are away? HOST SIBLING INTERESTS (To make the best match possible, please provide additional information about the hosting sibling.) Name of hosting sibling:
States’ 4-H International Exchange Programs 2014 SUMMER INBOUND HOST FAMILY APPLICATION If possible, please fill out the online version of this form instead of a paper version. The form is available on the States’ 4-H International website: () Print neatly or type HOST FAMILY INFORMATION (FOR 4-H OFFICE USE ONLY) FAMILY NAME ORGANIZATION STREET ADDRESS NAME CITY STATE ZIP ID CODE COUNTY FAX DATE of BIRTH GENDER AGE MAILING ADDRESS (if different) Chaperone hosting dates HOME PHONE HOST SIBLING CELL HOST SIBLING EMAIL ADULT # 1 NAME CELL PHONE Relationship to Delegate (eg host mom) BIRTHDATE (Optional) EMAIL: HOBBIES/INTERESTS/ PERSONALITY WORK PHONE EMPLOYER OCCUPATION ADULT # 2 NAME CELL PHONE Relationship to Delegate (eg host mom) BIRTHDATE (Optional) EMAIL HOBBIES/INTERESTS/PERSONALITY WORK PHONE EMPLOYER OCCUPATION EMERGENCY CONTACT DAY PHONE RELATIONSHIP OTHER FAMILY MEMBERS AND REGULAR OVERNIGHT ADULT GUESTS IN HOME (Place an “X” to the left of the host sibling.)* “X” NAME GENDER BIRTHDATE GRADE AGE (as of 7/21/14) Hobbies/Interests/Personality *If needed there is additional space on page 2 Why does your family want to host? Family interests during the summer: What languages are spoken in your home? Do you have any indoor pets? Yes No If yes, what animals & how many? Farm and/or Outdoor Animals: Type of Community: Urban Suburban Small Town Rural Non-Farm Farm Ranch # of acres and type of crop if applicable: Optional: What is your family’s religious affiliation, if any? Optional: How often do you attend religious services? Are there any physical, developmental or psychological health conditions in your family of which a delegate would need to be aware (ex: physical disability, Down syndrome, hearing loss, ADD/ADHD, Autism, etc.)? If both parents work outside the home, who will assume responsibility when both parents are away? HOST SIBLING INTERESTS (To make the best match possible, please provide additional information about the hosting sibling.) Name of hosting sibling:
host-family-application.docx