The Harvey School - Host Family Questionnaire

Host Family Questionnaire

50% of survey complete.

If you are interested in hosting an international student who attends The Harvey School, please answer each of the following questions.

The answers will be used to first screen appropriate families, and later match international students with compatible families. If you have any questions or need assistance, please contact Alex Lindquist, Director of International Programs, at 914-232-3161, Ext. 160, alindquist@harveyschool.org, or Robert Cook, Director of ISP, Rcook@harveyschool.org, ext. 131.

Thank you!

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* 1. Name of Applicant and Spouse

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* 2. Please provide your contact information

Street Address:

Town, State, Zip

Mailing Address (if different)

Home Phone

Applicant Cell Phone

Spouse Cell Phone

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* 3. Names and ages of children living in your home

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* 4. List any children who do not live in the home

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* 5. List any other adults living in the home (including relationship and age)

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* 6. Applicant's Occupation

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* 7. Applicant Background

Applicant's Employer Name:

Job Title:

Work Schedule:

Highest Level of Education/School:

Degree:

School Name:

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* 8. Spouse's Occupation

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* 9. Spouse Background

Employer Name:

Job Title:

Work Schedule:

Highest Level of Education/School:

Degree:

School Name:

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* 10. Please describe your home including:

Square Footage

# of Bedrooms

# of Bathrooms

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* 11. What is the approximate distance from your home to Harvey?

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* 12. Will your international student have his/her own bedroom?

Yes

If no, with whom will the room be shared? If yes, approximate room square footage?

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* 13. Will student have access to (check those that apply):

Bath

Shower

Washer

Dryer

Internet Access

Quiet Study Space

Computer

Telephone

Television

Iron

Other (please specify)

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* 14. What are your family's interests and hobbies?

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* 15. Do you have pets?

Yes

If yes, please give details.

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* 16. Do you allow smoking in your home?
(Please be aware that each international student
and his/her parents sign an agreement prohibiting
the use of tobacco, alcohol, and driving.)

Yes

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* 17. Are you flexible to accommodate a student who follows a particular dietary restriction? (e.g., vegetarian, kosher, gluten free)

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* 18. Does anyone who will be living in the household with the student have a significant medical condition (physical or mental)? If yes, please specify below.

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* 19. Describe your religious practices, if any

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* 20. What is your or your family's international travel experience?

None

Limited

Extensive

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* 1. Name of Applicant and Spouse

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* 2. Please provide your contact information

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* 3. Names and ages of children living in your home

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* 4. List any children who do not live in the home

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* 5. List any other adults living in the home (including relationship and age)

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* 6. Applicant's Occupation

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* 7. Applicant Background

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* 8. Spouse's Occupation

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* 9. Spouse Background

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* 10. Please describe your home including:

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* 11. What is the approximate distance from your home to Harvey?

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* 12. Will your international student have his/her own bedroom?

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* 13. Will student have access to (check those that apply):

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* 14. What are your family's interests and hobbies?

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* 15. Do you have pets?

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* 16. Do you allow smoking in your home?(Please be aware that each international studentand his/her parents sign an agreement prohibitingthe use of tobacco, alcohol, and driving.)

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* 17. Are you flexible to accommodate a student who follows a particular dietary restriction? (e.g., vegetarian, kosher, gluten free)

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* 18. Does anyone who will be living in the household with the student have a significant medical condition (physical or mental)? If yes, please specify below.

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* 19. Describe your religious practices, if any

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* 20. What is your or your family's international travel experience?

* 16. Do you allow smoking in your home?
(Please be aware that each international student
and his/her parents sign an agreement prohibiting
the use of tobacco, alcohol, and driving.)