Host Family Application Beaverton OR

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Host Family Application Beaverton OR Powered By Docstoc
					                  International Sustainability Leadership Project
                                            July 18 - August 5, 2011

                                          Host Family Application
           Typed or computer-generated applications are strongly encouraged. Return completed application to:
      Sister Cities Program / Office of the Mayor / City of Beaverton, Mailing: P.O. Box 4755 Beaverton, OR. 97076-4755
                                      Fax: 503.526-2479 / Email: tbaird@ci.beaverton.or.us

Adult Host #1 full name______________________________________________________________________
Adult Host #2 full name______________________________________________________________________
Address_______________________________________ City/Zip_____________________________________
Best Day Phone ____________________________ Best Even Phone__________________________________
Email Address #1__________________________________________________________________________
Email Address #2__________________________________________________________________________
Host #1 place of employment/title______________________________/________________________________
Host #2 place of employment/title______________________________/________________________________

List all members of the household: Name/Gender/Age
1.________________________________/_____________________________/_______________
2.________________________________/_____________________________/_______________
3.________________________________/_____________________________/_______________
4.________________________________/_____________________________/_______________
5.________________________________/_____________________________/_______________
6.________________________________/_____________________________/_______________

AUTO INSURANCE- Thank you for providing insurance information to help ensure everyone’s safety.
A copy of your policy may be requested.

Driver #1
Driver’s License #_______________________________________________________________
Auto Insurance Carrier___________________________________________________________
Policy #_______________________________________________________________________

Driver #2
Driver’s License #_______________________________________________________________
Auto Insurance Carrier___________________________________________________________
Policy #_______________________________________________________________________

Driver #3
Driver’s License #_______________________________________________________________
Auto Insurance Carrier___________________________________________________________
Policy #_______________________________________________________________________
Please indicate if you have pets in your home:                   Cats ___ Dogs ___ Other(s)_________________________

Will receive smoker _____                     Prefer non-smoker, but will accept smoker _____
Will not receive smoker_____                  Does anyone in your household smoke? Yes_____                             No_____

Host #1 country of birth (optional) _________________________________________________
Host #2 country of birth (optional) _________________________________________________

What languages are spoken in your household?_________________________________________________
__________________________________________________________________________________________

Please list your hobbies and special interests: ___________________________________________________
__________________________________________________________________________________________

Indicate briefly your main reasons for wishing to host a participant:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Please describe other hosting experiences you have had:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

If you have any additional comments you would like to include please use the space provided below:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Do you know of any other families that may wish to host students? If yes, please list their name/telephone
contact information below:
_______________________________________/__________________________________________________
_______________________________________/__________________________________________________
_______________________________________/__________________________________________________

Agreement and Waiver
I agree to a background records check by the Beaverton Police Department for every household member 18 years of age and over. I
certify that all of the above information is correct and I agree to stand by the policies and procedures set forth by the City of Beaverton
(COB) and partner institutions. I understand that COB and its affiliated institutions, in arranging this project, act only as agents. As
such, neither COB, nor any of its employees, or persons, parties, organizations, or agencies collaborating with them is or shall be
responsible or liable for injury, loss, damage, deviation, delay, curtailment, (however caused), or the consequences thereof which may
occur during any travel or project activities.

Host #1 Signature: ________________________________________________Date:_______________
Host #2 Signature: ________________________________________________Date:_______________

				
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