Host Family Application

Residents Full Names *

Please list the names and ages of all residents in the household. Please indicate gender (M or F) and indicate all adults (anyone 21 or older) with an (A).

Please list any pets in household (including birds, fish, reptiles, etc.):

Are you willing to host teens of another religion? *

Yes

No

If so, which religion: *

Christian

Jewish

Muslim

Any

Does anyone in your home smoke cigarettes, cigars or pipes? *

Yes

No

Would you prefer to host a boy, girl, or either? *

Boy

Girl

Either

How many teens would you be willing to host? *

Can you offer your visitor a private bedroom? *

Yes

No

If no, with whom would your visitor be sharing a bedroom?

During the program, who would typically be home during the day? *

During the program, who would typically be home during the evening? *

Would someone from your home be available to drive your visitor to and from program activities during the day? *

Yes

No

Would someone from your home be available to drive your visitor to and from program activities during the evening? *

Yes

No

Have you been a host family before? *

Yes

No

If so, please explain:

What do you hope to gain from hosting with Hands of Peace? *

If you have questions, call Gail Tatsuda at (847) 707-3717

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