Assignment - Simon 03/24
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Application for Host Family
Student Information
Student Name
Date of Birth
Month
January
February
March
April
May
June
July
August
September
October
Novemver
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
Grade Entering
Grade
12
11
10
9
8
Phone Number
Email Address
Multiple Choice
1. What would you consider to be the most enjoyable way to spend your time on a Friday evening?
Go to a party with friends
Play video games alone in your room
Curl up on the living room couch and read a book
Play a board game with your host family
Attend a musical concert
2. If your host family have pets, which animal or animals would you prefer?
Cat
Rabbit
Fish
Dog
Horse
None
3. What would be the most fun thing for you to do on a Saturday afternoon?
Go shopping in the city
Go for a mountain hike with your host family
Visit an amusement park
Visit an art museum
Dine at a restaurant
Watch a basketball game on television Play soccer with your friend
4. If your host parents asked you to help around the house, which one of these chores would you prefer?
Clean your room
Cook dinner for your family
Wash the dishes
Take the dog for a walk
Mow the grass
Shovel snow
None of them above
5. On a weekend morning, what would you rather do?
Rise early and go for a walk
Rise early and do homework
Rise early and cook breakfast for the family Sleep until noon
Sleep
6. If you lived a half mile or 0.8 kilometers from school, how would you prefer to travel to and from school during nice weather?
Car
Bicycle
Walk
7. If you were at a party with host family, friends and strangers, what would you enjoy doing the most at this event?
Talking with your friends
Spending time with your host family members
Meeting new people
Sitting at a quiet table by yourself
8. If you were sad about something, who would you confide in first?
Your own parents
Your best friend
Your host brother or sister
Your host parents
Guidance Counselor
No one
9. Which of these activities have you experienced before? Check all that apply.
Hiking
Rock climbing
Downhill skiing
Sleeping outdoors in a tent
Football
Baseball
Swimming
10. Which of these activities would you want to try for the first time? Check all that apply.
Sailing
Canoeing
Kayaking
Hiking
Rock climbing
Lawn mowing
Riding an ATV (All Terrain Vehicle) Roller skating
Ice skating
Downhill skiing
Cross country skiing Snowmobiling
Sleeping outdoors in a tent Snow tubing or sledding Jet skiing
Football
Baseball or softball
Short Questions
1. Have you ever lived with a host family? Where and for how long?
2. Are you and your parents open to a Host Family of any race, religion or ethnic background? If not, please explain.
3. Would you be willing to live with another exchange Student in the same host family, but in separate rooms? If not, please explain.
4. Have you ever lived with a host family? Where and for how long?
5. What are your favorite activities?
6. Would you be willing to live with a family that has cats and/or dogs?
7. Would you be willing to help your Host Parents with household chores?
8. Do you have any allergies? Please explain.
9. Are you taking any prescription medications? Please explain.
10. Do you have a health condition that your Homestay Parents should know about? Please explain.
11. List four words to describe yourself.
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