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HOST FAMILY APPLICATION FOR EXCHANGE STUDENTS FROM MITO, JAPAN Summer 2015 ---PAGE BREAK--- ASCC Host Family Application Page 2 BRING THE MAGIC OF JAPAN INTO YOUR HOME BY BECOMING A HOST FAMILY The Anaheim Sister City Commission (ASCC) is now accepting applications to host visiting exchange students from our sister city in Mito, Japan. Our Japanese guests will be visiting Anaheim from late July to early August (dates are being finalized) this summer and host families are needed to in order to house our guests during their stay in Anaheim. To qualify as a Host Family you must agree to all of the following conditions: 1. Have a suitable household that provides privacy and comfort for the visiting student. 2. Have a safe household equipped with fire alarms/smoke detectors as prescribed by the California Building & Fire Codes. 3. Have everyone in the household age 18 and over fingerprinted by the City of Anaheim Police department prior to hosting. 4. Assume responsibility for costs associated with the student’s visit, including food and entertainment. Completed applications must be submitted by May 15, 2015. Soon after you submit the completed application, you will be contacted by a member of the ASCC to set up a formal interview to determine suitability and to insure that you fully understand the important responsibilities and requirements of an Anaheim Host Family. All members of your family are required to attend the interview which will take place either in your home or at a mutually convenient location in Anaheim. If selected, you will be required to attend an orientation meeting where you will learn about the various exciting aspects of the Japanese culture and the students who will be visiting you home. This is a unique growth opportunity for your entire family to learn about a different culture and to share your American values and home life with a young individual from another land. If you are interested in hosting, please fill out the attached application and return to: Anaheim City Hall Attn: Erin D. Wahlen, 7th Floor 200 S. Anaheim Boulevard Anaheim, CA 92805 OR express your interest by emailing [EMAIL REDACTED] and we’ll update you as additional details are solidified, such as the dates of their visit to Anaheim. ---PAGE BREAK--- ASCC Host Family Application Page 3 ANAHEIM SISTER CITY COMMISSION STUDENT EXCHANGE PROGRAM HOST APPLICATION - 2015 Address Zip Adult Applicant Co-Applicant Last First M / I Last First M / I Occupation Month/date/year of birth Month/date/year of Home phone ( ) Home phone ( Work phone ( ) Work phone ( Cell phone ( ) Cell phone ( Fax ( ) Fax ( ) E-mail e-mail List all others living at home: Name Date of Birth Sex: M / F School Has any member of your household ever been convicted of a crime other than a minor traffic violation? Yes / No If yes, please Do you belong to any clubs or organizations? Yes / No Which ones? Do you have any pets? Yes / No (circle one) If yes, please list: ---PAGE BREAK--- ASCC Host Family Application Page 4 Family interests: (mark all that are applicable) ___Art Listening to music ___Sailing/boating ___Watching T V ___Baseball ___Museums ___Sewing ___Walking ___Basketball ___Movies ___Shopping ___Water skiing ___Backpacking/hiking ___Opera ___Snow sports ___Woodworking ___Bowling ___Painting/drawing ___Soccer ___Wrestling ___Camping ___Picnics ___Swimming ___Writing ___Computers ___Photography ___Table games ___Fishing ___Cooking ___Raising animals ___Tennis ___Golf ___Cycling ___Reading ___Travel ___Jogging ___Gardening ___Riding Horses ___Theatre Other: List any other hobbies or interests: Does anyone in your family play a musical instrument? Yes / No Who and which instrument? Does anyone in your family speak a language other than English? Yes / No Who / what language? Will the student have to share a room? Yes / No If yes, indicate the name, sex, and age of the child. Does anyone living in your family home smoke? Yes / No Exchange student preference: Male_____ Female No Preference Have you hosted an exchange student before? Yes / No When and from what country? Describe your home, e.g. # bedrooms, baths, pool, etc. Does your home have properly installed and functioning smoke detectors? Yes / No Why do you want to host a student? ---PAGE BREAK--- ASCC Host Family Application Page 5 List two emergency contacts: Name Address City St Zip St___ Home Phone ( ) Home Phone ( Cell Phone ( ) Cell Phone ( Host applicants and their families understand and acknowledge by their signatures that Anaheim Sister City Commission (ASCC) maintains jurisdiction over all aspects of the program. In the event of any problem between the student and the host family, ASCC reserves the right to remove the student at any time to resolve the situation. I/we confirm and acknowledge that an ASCC representative explained the program to my/our satisfaction and answered all questions. If selected, I/we will be scheduled to attend a host family orientation prior to student arrival. I/we also understand that hosting/housing costs are the sole responsibility of the host family. There are no financial subsidies available. On most days the host family provides breakfast and dinner for their exchange student. The costs associated with the planned/itinerary daily activities for each exchange student are the responsibility of ASCC. Transportation to and from the daily drop off point is the responsibility of the host family. Hosts should also provide or assist with laundry needs as necessary. Weekends are normally available for the host family to plan activities for their exchange student and costs associated therewith are the sole responsibility of the host family. Host parents will be encouraged to participate in a minimum of one day of activities (usually a weekday) as a chaperone. Student applicants are judged on their individual merit at the time of application. Information provided by the host applicant in this document is for the sole use and purpose of determining eligibility as a hosting family for incoming exchange students. Said information is confidential and is viewed or accessed only by the ASCC Cultural/Government Exchange Subcommittee. If this application does not provide sufficient space to answer questions or make comments, please attach additional page(s) to meet your needs. In submitting this application, we certify that the information provided is complete and accurate to the best of our knowledge. We also understand the obligations outlined above and agree to all conditions imposed or implied by the Cultural/Government Exchange Subcommittee. Falsifying this application will result in disqualification. Signatures: Applicant Co-Applicant Return Application to: Anaheim City Hall Attn: Erin D. Wahlen, 7th Floor 200 S. Anaheim Boulevard Anaheim, CA 92805 Email: [EMAIL REDACTED] Received by: