Host Family Application Step 1 of 5 20% Applicant's Name* First Last Co-Applicant's Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Enter Email Confirm Email PhoneMobile PhoneFaxMarital Status Single Married Divorced Widowed Age Range* Under 30 30-39 40-49 50-59 60-64 65+ Please specify: Employment InformationApplicant's Occupation Applicant's Employer Applicant's Work PhoneBest Time to Call Co-Applicant's Occupation Co-Applicant's Employer Co-Applicant's Work PhoneBest Time to Call Members of Household(Not including Applicant and Co-applicant, listed above)Household Member 1: Name Household Member 1: Gender Male Female Household Member 1: Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Household Member 1: Relationship Household Member 2: Name Household Member 2: Gender Male Female Household Member 2: Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Household Member 2: Relationship Household Member 3: Name Household Member 3: Gender Male Female Household Member 3: Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Household Member 3: Relationship Household Member 4: Name Household Member 4: Gender Male Female Household Member 4: Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Household Member 4: Relationship Background InformationAre you a US citizen? Yes No Please specify country: Have you or any member of your household been convicted of a crime? Yes No Please explain: Do you or any members of your household belong to an organization or club? Yes No Please explain: ReferencesProvide four references including friends and neighbors:Reference 1: Name Reference 1: PhoneReference 2: Name Reference 2: PhoneReference 3: Name Reference 3: PhoneReference 4: Name Reference 4: Phone Profile InformationReligion/Religious Affiliation Interests and HobbiesLanguages Spoken In Your Home Has your family ever hosted? Yes No Do you or any members of your household smoke? Yes No Would you permit smoking outside of your home? Yes No Do you have pets in your home? None Dog Cat Please indicate hosting preference: Male Female Either Do you have a preference of the meal plan option you are able to host: B&B (breakfast only) Deluxe (breakfast 7 days and dinner Monday – Thursday) Supreme (breakfast and dinner 7 days per week) No preference Home EnvironmentWhich is the closest Metro train station to your home? Approximate distance from home to Metro train station (miles): Approximate distance from home to Metro bus stop (blocks, miles): Do you have Internet access for participants' use? Cable DSL Wireless Dial-Up None How many bedrooms available for homestay? How many shared full baths? How many private full baths? Is there anything you would like potential homestay participants and Just Like Home to know about you and your family?Describe your typical family weekend: Health InformationDo you consider your health to be: Excellent Good Fair Do you have any medical problems we should know about? Yes No Please explain: Do you have any dietary restrictions, i.e. vegetarian, kosher, etc.? Yes No Please explain: Do you have any allergies? Yes No Please explain: Have you participated in therapy or counseling in the past two years? Yes No Please explain: MiscellaneousHow did you hear about our program? Email Advertisement Friend Name of Friend Can you suggest other friends and families who might be interested in hosting an international visitor? Yes No Please provide names and telephone numbers below:By clicking below, you are certifying that the information provided above is complete and accurate. You are also acknowledging that you have read and understood our legal notices, and that you are at least 13 years old. CAPTCHA Δ