ࡱ> PROY bjbjWW m==] $ DDDDD  $ v W@ DDD DD  M VE @ D0`Y } Lions International MD 37 Youth Exchange Program Host Family & Host Lions Club 2002 Application Form INSTRUCTIONS: The prospective Host Family shall complete Part I and Host Lions Club shall complete Part II of this form. If more than one family is involved in the hosting, separate applications shall be completed. A recent group photograph of the family and a letter of introduction describing the home life of the Host Family shall also be attached. PART I. HOST FAMILY DATA: Family Last Name: ______________________ Husband First Name: ____________ Wife First Name: _____________ Mailing Address: _______________________________ City: _______________ Province: ______ PC : _________ Home Phone: _____________________ Business Phone: ___________________ Fax: _____________________ Email______________________________________________ Husbands Occupation: ______________________________ Wifes Occupation: _______________________________ Lions Club Members: Husband: Y / N Wife: Y / N Club Name(s): __________________________________________ Name, ages & sex of children who will be at home during visit: ______________________________________________ __________________________________________________________________________________________________ National Origin: Husband: __________________________________ Wife: ____________________________________ Family Religion: _______________ Languages Spoken: ____________________________________________________ Family interests and pastimes: ________________________________________________________________________ Home Location: City. Town.Village.Farm.Acreage.Single Family Dwelling.Apartment Population of City: _____________________ Average Climate: __________________________ Pets in the Home: ____________________________________________________ Previous Hosting Experience: _________________________________________________________________________ HOST FAMILY PREFERENCES: We would prefer youth to be a:. Girl.Boy..Either Age: ________ Special field of interest we would suggest our youth to have: ________________________________________________ Smoking (will / will not) be allowed in our home. We are willing to host ___ youth for: Period 1, July 15 to July 28 and ___ youth for Period 2, Aug 3 to Aug. 16 Other dates: _____________________________ Comments:_________________________________________________ We promise that one parent or some other responsible person will be at or near home during the period of our youths stay. Further, in fairness to the youth and any other Host Family that may also be involved hosting the same youth it is understood we shall relinquish ties during the time when the other family is hosting him or her, unless agreed to by the Families. Signature of Host Husband: _________________________________ Signature of Host Wife: ____________________________________ Date ________________________ PART II: To be completed by Host Lions Club. A Lions Club shall supervise the hosting of each exchange youth in the area where the hosting will take place. Club: ______________________________________________ District: _______ Coordinating Club President / YE Chairman Name: ____________________________ Mailing Address: _______________________________ City: _______________ Province: ______ PC : _________ Home Phone: _____________________ Business Phone: ___________________ Fax: _____________________ Email______________________________________________ I have personally interviewed the named Host Family and accepted their application. I certify they have been fully informed of theYE Programs requirements and procedures and are qualified to serve as hosts. Signature of Lions Club President / YE Chairman: _______________________________ Date: __________________ Signature of District YE Chairman: ____________________________________________ Date: _________________ PART 111: To be completed by the MD 37 or District Youth Exchange Coordinator: Name of Youth assigned: ____________________________________________ From the Country of:_________________________ Copy of Youth Application provided to Host Family on this _____day of ______________, 2002 The following are on file: Insurance Certificate: Y / N Indemnity Form: Y / N Emergency Medical Authorization: Y / N Travel Arrangements: Arrival Date: __________________ Airport: _________________ Flight: ________ Time: ___________ Departure Date: ________________ Airport _________________ Flight: ________ Time: ___________ Inland travel details between Host Families if applicable: ____________________________________________ Other Host Family or Families: _________________________________________________________________ Local Youth Exchange Coordinator responsible for youth: Name: _____________________________________ Mailing Address: _______________________________ City: _______________ Province: ______ PC : _________ Home Phone: _____________________ Business Phone: ___________________ Fax: _____________________ Email______________________________________________ The following parties shall have copies of this application for their records. 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