USAI Host Family Data Form

USAI Host Family Data Form

Complete form below to sign up. You will receive a Thank You message indicating form has been subitted. If you don't receive an email please contact us right away. Thanks.
Full Contact Name

First NameLast Name
Which program are you interested in?
Name of Camp or School
Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact E-mail:
Contact Phone Number Best Way to Reach You

Area CodePhone Number
Mobile Number

Area CodePhone Number
Gender
Date of Birth

MonthDayYear
Occupation
Home/Work Phone Number

Area CodePhone Number
Are you the only adult at home?
How many Children live at home?
Other Adult Family Member Name

First NameLast Name
Adult Family Member Number

Area CodePhone Number
Occupation
Gender
Date of Birth

MonthDayYear
Other Family Members Names & Ages
Other Family Members Names & Ages
Other Family Members Names & Ages

How did you hear about this program?
Please descibe your inerest in hosting an international student.
Have you hosted before?
Please describe your previous hosting experience, if any.
Are any second languages spoken by family members at home?
Please describe and indicate the degree of fluency in each language and whether any languages other than English are regularly spoken at home.
Have any members of your family visited a foreign country?
Please describe.

Please describe your hometown (proximity to nearest city, lake, river, park, etc.) Is your home in a suburban or rural area? What's the population and what are your neighbors like?
Please describe your home.
Please describe the members of your family.
Does anyone in your family smoke in the house?
Do you have pets?
If so, please describe (cat, dog or other, personality, where they sleep, etc.)
Will your international student be sharing a room?
Please describe where your international student will be sleeping.
Does your family have any special dietary needs (medical, religious, etc.)?
Please describe.

Please describe your expectations of your international student's behavior during the time he/she is in your home (curfew, cleaning, laundry, downtime, general attitude).
Please describe a typical summer weekday in your home.
Please describe a typical summer weekend in your home.
Does your family practice a religion?
Please describe, and in particular how your family's religious practices form part of your daily or weekly activities.
Does any member of your family have a chronic or serious illness?
If so, please describe.
Does any member of your family have a disability, nervous or mental disorder?
If so, please describe.
Have you or any member of your family (or anyone who might be visitng your home) been charged with or convicted of a crime?
If so, please explain.

Reference #1: Professional (non-family/friend)

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Reference #2

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
I (We) give permission to USAImmersion LLC (USAI) to perform criminal background checks on the adults resident in our home during the international student’s stay. I (We) agree that should our host student or his/her family contact us about returning next summer, we will contact USAI to ensure that the student is processed through one of USAI’s Family Immersion programs. I (We) agree not to host any other international students during our USAI student’s stay with us without notifying first (unless we have already notified USAI), and that we are not listed as an emergency family for any other student placement agencies during this period. I (We) agree to follow the guidelines published on the USAI website’s “Host Family Corner” section and any other written or verbal instructions provided. I (We), individually and together, as the Host Family, hereby agree to release USAI, its successors, agents, affiliates (USA Immersion, Inc.) and representatives from any and all liability, losses, damages, judgments or expenses, including attorney fees, that it may incur or sustain as a result of any claims, demands, action or causes or action that arise out of, occur during, or are in any way connected with our participation in the Homestay Program and/or any travel incidental thereto. We, the Host Family, accept full risk and responsibility for any injury we may incur, or for any damage to our property that arises from our participation (students carry liability insurance for this purpose.)

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