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Homestay Request Form
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Please fill out the information below.

Your Details
First Name
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Last Name
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Email Address
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1) Brothers and sisters (please include age and gender)
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2) Have you traveled outside your country before?
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3) Have you ever participated in a homestay program?

If yes, rate your experience:
Not good Okay Very good
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4) Do you enjoy animals as family pets?
Yes No
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5) Would you enjoy children as part of the family?

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6) Do you smoke?
Yes No
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7) Would you mind if there are smokers in your homestay family?
Yes No
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8) What hobbies, sports or other activities do you enjoy?

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9) Are you planning to drive a car?
Yes No
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10) How much interaction with your homestay family do you prefer?
Every day. I want daily conversation.
Several times a week and on weekends.
I’m very independent and prefer to interact only when necessary.

Your Health Information
11) Do you have any allergies to food, drugs, animals or medications?
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12) Are you a vegetarian, someone who eats no meat?

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13) Do you take any medications regularly?

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14) How would you describe your present condition of health?
Poor Average Excellent

Father's Details
First Name
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Last Name
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Occupation
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Father’s work Phone#
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Email Address

Mother's Details
First Name
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Last Name
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Occupation
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Mother’s work Phone#
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Email Address

TERMS AND CONDITIONS

1. Participant and his or her heirs, assigns, or other successors in interest agree to release Community Colleges of Spokane representatives, agents and host families from any responsibility and liability of changing who the host family will be prior to or after arrival in the United States; and/or placement in more than one family through the stay.

The participant also agrees:
2. To be responsible for carrying valid insurance through the entire homestay period covering at a minimum sickness, accident and personal liability on his/her personal belongings.

3. To authorize CCS and the host family to seek medical attention for himself/herself in the event of sickness, accident or other emergencies during the time the student is living with the family. Permission also is granted to release information regarding his/her health to outside physicians and facilities. In all cases, participant agrees that CCS and the host family are not to be held liable or responsible for any aspect of medical treatment received.

4. That CCS will not be held responsible and that he/she will reimburse the host family for the repair or other costs incurred by the student in case of damage to the host family’s home.

5. That CCS will not be held responsible for negligence on the part of the family or the participant pertaining to home or person when damage, injury or death is result.