kic homestay application (for new hfs) v2012.pdf

7/28/2019 KIC Homestay Application (for new HFs) v2012.pdf

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Kaplan International Centers - Home Stay Application

Personal Information

Name Date of BirthLast First Middle

Address

Street City State Zip Code

Occupation

Social Security Number Drivers License Number

Occupation Phone

Home Work Cell

Email _____________________________How should we contact your during the day?____________________

Weekday Work Hours Weekend Work Hours

Co-Host Information

Name Date of Birth

Last First Middle

Occupation Phone

Home Work Cell

Weekday Work Hours Weekend Work Hours

Other Household Members

Name Age Gender Relationship

Home Information

Type of Home House Condo Apartment Othe

Number of Bathrooms for Students Shared with Family Private for Student

Number of Bedrooms for Students Single Shared


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Distance to the school

Transportation Information (bus #, etc.)___________________________

Travel Time to School (door to door via public transportation)

Miscellaneous Information

Pets Who Are Allowed Inside Dogs Cats OtherNumber Size and Breed Number

Pets Who Live Outside Only

Does Anyone in Your Family Smoke? Inside Outside

Can the Student Smoke? Inside Outside

Can the Student Drink Alcohol? Inside Outside

Can the Student Access the Internet? Own Computer Family Computer

Can the Student Use the Laundry Facilities? Frequency?

Have You Hosted Students Before? Yes No

If Yes, How Long? How Many? Nationality(ies)

What Other Agency/School Provides You with Students?

Native Language(s)

Language Spoken at Home Other Language Abilities

Eating Habits

Breakfast AM With Family Individually

Dinner PM

Will You Host a Vegetarian Student? Yes No Vegetarians Only

Our Typical Family Dinner Consists of

Describe any Kitchen Restrictions or Dietary Habits (e.g., vegetarian etc.)


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Addit ional Information

How Do You (and Your Family) Spend Your Free Time?

What Activities Can the Student Expect to Share with You (and Your Family)?

Please Tell Us Any Additional Information About Your Family:

Do You Prefer (If No Preference, Please Leave Blank) Female Male Couple

Do You Have Any Special Requests or Comments About Your Students?

ReferencesKIC requires at least two personal references. Your references should be individuals qualified to give an opinioof you on a personal level. Please complete below.

Reference 1

Name Telephone

Relationship

Reference 2

Name Telephone

Relationship

For Office Use Only

Reference 1

Date ContactedPerson Spoken ToContacted By

Reference 2

Date ContactedPerson Spoken ToContacted By


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I have carefully read this application and all of my answers on this application are true and complete. I understand thcompletion of this application does not guarantee that I will be selected to host students. I further understand that as part this application and from time to time as an update to the application, a background check will be conducted for verificatio

purposes. I authorize Kaplan International Centers and its agents and representatives to investigate and verify all of tstatements made in this application and in connection with this verification, to disseminate the information contained herein tany person. I authorize all persons, companies, schools or other entities listed in this application to verify for KaplaInternational Centers any information regarding this application and from time to time any updates thereto. I hereby releaAspect Education Ltd, its parent company and affiliates and each of their officers, employees, agents, and representativeand all of said persons, companies, schools and other entities from all liability for any damage that may result from furnishinsuch information.

My signature below indicates that I have read the above stated policies of Kaplan International Centers and agree to abide the general rules and conditions of the Kaplan International Centers Host Family program.

Host Family Signatures (if married couple, both spouses must sign)

Printed Name Signature Date

Printed Name Signature Date

Kaplan International Centers STAFF:

Name and Title Date

kic homestay application (for new hfs) v2012.pdf

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