Host Family Request Form

This form is for students who wish to have a host family.

Is this your first request for a host family?
Type yes or no
Family Name:
First Name:
Date of birth:
 Month Day Year
Gender:
 Male  Female
Native City and Country:
How many months do you plan to study at the ELI?
Your address while at the ELI

Street Address:
City:
State:
Telephone number:
Is this a cell phone?
 Yes   No
E-mail address:
Are you

Buddhist Catholic Christian Muslim Jewish none

Your class level at the ELI:
 Listening/Speaking  Reading/Writing  

Do you have a car?
 Yes    No
Do you smoke?
 Yes   No
Are you ok with cats?
 Yes   No
Are you ok with dogs?
 Yes    No
Are you married?
 Yes    No
Do you have children?
 Yes   No
What family members are here with you?
Would you like to attend church with your host family?
 Yes   No
What are your interests?
What is your university major?
What are your future plans?