Online Application for Host Family

CONTACT INFORMATION

* Address   * City   * State   * Zip Code     AK AL AR CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
* Family/Last Name   * First Name   Middle Name     * Email   * Day Time Tel   * Evening Time Tel   ( ) -   ( ) -
HOUSEHOLD MEMBERS
Name   Relationship   Sex DOB (MM/DD/YY) Occupation     Male Female     Male Female     Male Female     Male Female     Male Female
GENERAL INFORMATION
Primary language spoken at home :	English Chinese French German Italian Japanese Korean Portuguese Russian Spanish
Secondary language spoken at home :	N\A Chinese English French German Italian Japanese Korean Portuguese Russian Spanish
List all pets :
Which pets are allowed indoors?
If yes, which school?
Do you host students from other schools?	Yes No
Interests or activities engaged in as a family or with students :
Type of Home :	House Condo
No. of bedrooms :	1 2 3 4 5 6 7 8 9
No. of bathrooms :	1 2 3 4 5 6 7 8 9
No. of bedrooms for hosting :	1 2 3 4 5 6 7 8 9
Other amenities (i.e., pool, gym, etc.):
Student's bathroom :	Private Shared
Please list student's room amenities (i.e., telephone, television, computer, etc.):
Any additional information about your house:
Public transportation accessible from your house:	Bus Metro Bus/Metro
Campus :	Los Angeles Irvine Pasadena
Estimated commuting time to campus, including walking and wait time:
HOSTING REQUIREMENTS & PREFERENCES
Your monthly rent :	$ /month
Gender preference :	Female Male No Preference
May students prepare their own food?	Yes No
Smoking policy :	Inside/Outside Outside only Not Permitted
Requirements related to religious practice:
Any additional requirements, preferences, rules, etc.:
Upload picture: File Name : Result :
I have read and agreed to POLY's Applicant's Statement