Confidential References

To the person completing this form on behalf of the Host Family: The student and family are applying to host a Costa Rican high school student participating in the Oregon/Costa Rica Partners of the Americas Student Exchange Program. Its purpose is to develop a closer relationship and understanding between the people of Costa Rica and Oregon. Oregon families provide home stays for Costa Rican high school students during December, January, and February.

Confidential Reference

Host Family Student Name*
First Last
Your Name*
First Last
Your Personal Email*
Your Place of Employment
Daytime Phone
Relationship to the family*
How long have you known the family?*
How often do you see the family?*
How do you feel that this family will adjust to unexpected situations, different customs, etc?*
How do you feel this family will welcome a visitor of a different religion and different ethnic background?*
What are the family's greatest strengths?*
What are the family's greatest weaknesses?*
Are you aware of any drug, alcohol or child abuse on the part of any member of the family?*
- Yes
- No
If YES, please explain
In your opinion, would a young visitor find this family supportive and understanding of difficulties in adjusting to different customs, new food, interpersonal relationships etc?
If you had/have a son or daughter age 12-18, would you feel comfortable if your child was placed with this family?*
- Yes
- No
Do you recommend this family to host a participant?*
- Yes
- No
Electronic Signature*
Signature Date*
Date Format: MM slash DD slash YYYY

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Confidential References

Confidential Reference

In your opinion, would a young visitor find this family supportive and understanding of difficulties in adjusting to different customs, new food, interpersonal relationships etc?