Hosting Application Step 1 of 3 33% Host Family InformationOregon Host Student Name* First Last Oregon Host Student Age*Grade in 2019-2020 School Year*FreshmanSophomoreJuniorSeniorHigh School*Hosting Family Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Hosting Family Phone*Primary Email* Secondary Email Hosting RequestsPreferred Session*Preferred SessionSession 1: Dec 7th, 2019 to Jan 4th, 2020Session 2: Jan 5th, 2020 to Feb 2nd, 2020Do you have flexibility to do either session if needed?*Preferred SessionYes, I could host either session.No, I can only host during my preferred session.Male or Female*male, female, or eitherMaleFemaleEitherHow did you learn about our program? Classroom presentation Internet Search/Website Teacher Informational Session Friend/Classmate Family Member Video Signs, Posters, Flyers at my school Other Spanish Teacher's NameSpanish Teacher's Email AddressParent InformationFathers Name First Last Fathers OccupationFathers Address (If different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Fathers Cell PhoneFathers EmployerFathers Schedule (Hours/Days)Fathers Birth Date Date Format: MM slash DD slash YYYY Mothers Name First Last Mothers OccupationMothers Address (If different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Mothers Cell PhoneMothers EmployerMothers ScheduleMothers Birth Date Date Format: MM slash DD slash YYYY I acknowledge/approve a criminal background check will be run on any adult 18+ living in the household* Yes No I acknowledge/approve that confidential references may be contacted to determine suitability of the hosting situation.* Yes No Household Members InformationListing of all parents, brothers, sisters, relatives or others living in the household.Member NameRelationshipBirth DateAgeMember NameRelationshipBirth DateAgeMember NameRelationshipBirth DateAgeMember NameRelationshipBirth DateAgeMember NameRelationshipBirth DateAgeIs English the primary language spoken at home* Yes No If NO, what language(s) are spokenWhat pets do you havePet(s) Stay Indoors Outdoors Both How frequently do you participate in church activitiesChurch Activities - Monthly01 - 23 - 45 or MoreChurch Activities - Weekly01 - 23 - 45 or MoreIf you attend church, would your host student be expected to attend with you Yes No Optional AffiliationWould there be a problem hosting a student of a different race/religion Yes No If YES, please explainHousehold InformationWill the student share a room*YesNoIf YES, with whom(The student must have their own bed but it is perfectly acceptable to share a room with a family member of the same gender.)Has your family previously hosted an exchange studentYesNoIf YES, what program/countryWill you be hosting any other exchange students or Spanish-speaking visitors at this timeYesNoIf YES, from where and what dates If you know a specific student who is traveling in the group and would like to host them, identify them below.Specific Students Name Has anyone currently living in the household ever been arrested and/or convicted of a felony or misdemeanor?Felony*YesNoMisdemeanor*YesNoIf YES, please explain belowBrief Medical InformationDoes any family member currently have:A serious or chronic illnessYesNoAny disability, nervous or mental disorderYesNoIf YES, please explain belowDietary RestrictionDietary Restrictions?VeganVegetarianGluten FreeOtherIf you chose OTHER above, please explain belowPlease upload recent photos of family membersTo help with identification, please name the photos with the name of the individual. (e.g. johndoe.jpg) Please only upload a single photo. Larger images will cause issues with form submission so please keep the image file size to a minimum.Upload Photo(s) Drop files here or Oregon / Costa Rica High School Exchange Program Host Family Application - Part IITo be completed by a parentHost Student Name* First Last Please briefly describe your neighborhood and your residence*(Include number of bedrooms, bathrooms, urban or rural, etc.)Why are you applying to be a host family*Describe a typical evening for your family and how your exchange student might fit into these activities and experience your community.*Please describe your family interests/hobbies* To the best of my ability, I am willing to help my Costa Rican exchange student improve his/her English and, in order to promote a truly positive experience, I shall ensure that he/she is included in as many of our activities as possible during the 4 weeks that we are a host family. Electronic Signature of Host Parent(s)*Signature Date* Date Format: MM slash DD slash YYYY Oregon / Costa Rica High School Exchange Program Host Family Application - Part IIITo be completed by the host studentHost Student Name* First Last Birth Date Date Format: MM slash DD slash YYYY Email Address Cell PhoneAre you in regular attendance at schoolYesNoApproximate days absent last yearDo you have a part-time job*YesNoHow many hours per week will you be working during the month you'll be hostingWhat jobs do you have at home*What do you do in your spare time*(Please list favorite hobbies and pastimes)What school/community/church clubs are you involved in*What kind of music do you like?*Do you play a musical instrument? If so, which one(s)*What are your favorite school subjects*Do you play any winter sports? What and How many hours per week*Do you like to read? If so, what kinds of books or magazines*What is types of TV shows/movies do you like to watch?*Please add 3 to 5 words or phrases that best describe you*Based on your extra curricular activities (sports, job etc.), Do you feel you have enough time to devote to making your Costa Rican brother/sister welcome and part of your daily life?To the best of my ability, I am willing to help my Costa Rican brother/sister improve his/her English and, in order to promote a true friendship, I shall include him/her in as many activities as possible during the 4 weeks that I am the host student.Electronic Signature of Host Student*Signature Date* Date Format: MM slash DD slash YYYY CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.