Part 1- Host Family Composition
Thank you for applying to be a host family for Fredericksburg Academy! Please be sure to fill
in all applicable fields.
Please be sure to enter the preferred email address to which all further notifications will be sent
under Host Parent 1.
Please complete the table below for all household members who will be living at home for a total of
10 days or more during the international student’s program; please be sure to answer ‘yes’ to the
questions “living at home?”. This includes children away at school or university who will be home
on weekends and/or holidays. All household members ages 14 and older will be required to
undergo a criminal background check.
No.
1.
2.
3.
4.
5.
6.
Title
Legal First
Name
Middle
Name
Last Name
Gender
Employer/School
Birth Date
(MM/DD/YY)
Country
of Birth
Family Title
(Father/Mother,
Brother/Sister,
Aunt/Uncle,
Etc.)
Level of
Education
Contact Phone
Living
at
Home?
Yes/No
Parent Information
Host Parent 1 (Primary Contact Person)
Name
Occupation Job Title
Employer
Host Parent 2
Name
Occupation
Job Title
Employer
Primary
Email
Primary
Email
Mobile
Phone
Business
Phone
Fax
Mobile
Phone
Business
Phone
Fax
Residence and Community
Residential Address
Address
State
Home Phone
City
Zip Code
Mailing Address, leave blank if same as above
Address
State
Zip Code
Home Phone
Home
Fax
City
Home
Fax
1. Type of Home ________________ (e.g. townhome, single family, apartment, etc.)
2. (a). Is this residence part of a functioning business (e.g. farm, daycare, office, etc.) ______
(b). If yes, are there employees who work at your home as part of your business? _______
(c). If yes, please explain the levels of access the employees have to the living areas of your
home.
3. Briefly describe your home (number of rooms, bedrooms, yard, etc.)
4. Will the student have his or her own bedroom? ______
a. If not, who will share a room with the student? ________
5. Briefly describe the neighborhood you live in (Is it gated, do you have neighbors, etc.?)
6.
7.
8.
9.
Is your home in a: City?______ Suburb?_____ Town?____ Village?______ Rural Area?______
Population of your Community____________
Name of Nearest City________________ Distance to Nearest City_____________
Briefly describe your community
School
Distance from Home to Fredericksburg Academy: Miles _________ Minutes__________
How will the student get to school? FA Bus____ Car_____ Other_______
What, if any, family members will attend school with the student_________________________
What, if any, family members are affiliated with the school as an employee_________________
Placement Criteria
Would you feel comfortable hosting a student who follows a particular dietary restriction? (e.g.
food allergies, Kosher, vegetarian, vegan, gluten-free, etc.)? _____
Would you feel comfortable hosting a student who smokes? _____
Does anyone in the family follow any dietary restrictions? _____
If yes, please explain.
Do you expect the student to follow the above dietary restrictions? Please explain.
Does anyone in your family smoke? _______
Inside or outside of the house? _________
Do you have any pets?_____
Please list the type and number of pets.
What is the primary language spoken at home?______________
What other languages are spoken at home? ________________
What languages are known by family members, and with what fluency?
Have you ever hosted with another exchange organization?_______
If yes, which organization(s) and dates of hosting
Has anyone in your family ever lived outside the U.S.A? _____
Please specify who, which countries and for how long.
Has anyone in your family ever traveled outside the U.S.A? ____
Briefly mention who, which countries and for how long.
What is your religious affiliation, if any?______________
How often do you participate in religious services or activities?
If you attend religious services or activities do you expect the student to attend with your family?
_____
Would any member of the household have difficulty hosting a student whose religious beliefs were
different of their own? _____
Describe any special circumstances (eating habits, unusual work hours, parents who travel often,
etc.) to which the student will need to adapt to in your family.
Part 2- Confidential Form
Instructions:
Please fill in all applicable fields. Please note that this information you disclose in this form will not
be shared with your hosted student.
Has anyone living in the home received professional counseling within the past five years?_____
If yes, please describe the dates of the treatment, how the situation affects the family members’
everyday lives, and if the family member is currently in a stable condition.
Does anyone in the home have a serious illness, chronic medical condition, or physical or mental
disability, or take any medications for mental health conditions? _____
If yes, give a brief description.
Has any member of your household ever been charged with any crime? ______
If yes, please give a brief explanation including date of charges, reason for charge, and outcome.
Has anyone living in the home ever had his/her driver’s license suspended or revoked?_______
If yes please give brief explanation which gives date license was revoked, reason, and date of
reinstatement.
Part 3- Host Family Description
Why is your family interested in hosting an exchange student?
Please indicate the major interests, hobbies and activities of members of your family. Include any
sports or fitness activities, religious activities, volunteering, etc.
Describe each member in the family (including yourself) in terms of personality, activities,
achievements and interests, etc.
Describe a typical weekday in your family.
Describe a typical weekend in your home.
When you do something special on a weekend, what might you do?
Describe any common family activities in a week or in the month. This can include: swim meets on
Fridays, church on Sundays, monthly movie night, etc. Be specific about who attends and how often
it occurs.
How does your family celebrate birthdays? What specific things are your family traditions for
birthdays?
What other holiday traditions does your family celebrate or take part in? Describe the different
holidays you celebrate and how you celebrate them. Be sure to mention any particular traditions
for the holidays you celebrate (Hanukah, Christmas, Kwanzaa, Ramadan, Diwali, Easter,
Thanksgiving, etc.).
Describe what is important to your family. What are your family values?
What are some of your family’s rules? Think about the unspoken rules or actions you might have as
well. Are children required to check in with parents when they are going somewhere different; do
you answer the phone if you are the closest? Does everyone sit and watch the news together after
dinner?
Describe your expectations regarding the responsibilities and behavior of the student while in your
home (chores he or she will participate in, curfew, computer time, etc.).
What personal expenses do you expect to be covered by the student? (e.g. shampoo, toothpaste)
Are there any upcoming family trips for which the student will be expected to contribute? When are
these trips scheduled?
How do you envision the student’s involvement in your family?
How do you hope to help ease the transition into your family?
What things would you like to do over the year with your student? What special trips or excursions
do you hope to make?
What would you like to learn as a family about your student and his or her home country?
What are you most excited about?
Part 4- Host Student Letter
Please write and attach a letter to your student telling them about your family. Have each member
write something about themselves and what they are excited for, and any other personal things or
messages they would like to relay to the student. Be sure to talk about family responsibilities and
things your family enjoys doing together. Also please send or attach some photos of you and your
family for your student with captions describing the pictures. You can send the pictures to
admission@fredericksburgacademy.org. These pictures could be your family and you doing
everyday activities, any pets, the home or the student’s room, or anything else you would like to
share with them before they arrive.
Signature of Host Parent 1
Date
Signature of Host Parent 2
Date
There shall be no discrimination by the School in the selection of the Board of Trustees, the employment of personnel, in
the admission of students, or in the administration of the School programming because of race, color, religion, national
origin, sex, age, sexual orientation, or handicapped status in violation of existing state or federal law or regulations.
Notice: Fredericksburg Academy reserves the right at all times to modify its admission requirements and to discontinue,
modify, or change its educational programs when it determines that it is in the best interest of the school to do so.
Fredericksburg Academy · Office of Admission · 10800 Academy Drive · Fredericksburg, Virginia 22408
540.898.0020 · Fax: 540.898.8951 · www.fredericksburgacademy.org
admission@fredericksburgacademy.org