International Homestay Agency  - Chico 
www.internationalhomestayagency.net 
Revised 09/06/12   
1 

International Homestay Agency - Chico 
4102 Nighthawk Way 
Chico, CA 95973 
Phone: (530) 321-0902 
Email: lynda@internationalhomestayagency.net 
Website:  http://www.internationalhomestayagency.net 

HOST FAMILY APPLICATION & AGREEMENT 

Family Name________________________________________________________________ 
 
Address____________________________________________________________________ 
 
City, State, Zip_______________________________________________________________ 
 
Telephone____________________________________ Fax___________________________  
 
Email____________________________________________ 
 
Family Members Living At Home 
 
Number of Adults________  Number of Children________   
  
Name:       Age: _____  
 
Name:       Age: _____  
 
Name:       Age: _____  
 
Name:       Age: _____  
 
Name:       Age: _____  
 
Others living in home and their relationship to your family 
 
Name:    ____ ___ Age: _____ Relationship: ________________ 
 
Name:     ___ Age: _____ Relationship: ________________ 
 
Professions of the adults in your family_______________________________________ ___ 
 
__________________________________________________________________________ 
 
Pets 
Please list the pets (dog, cat, etc.) in your family, and if they are kept inside or outside the home. 
 
______________________ Inside____ Outside____ Both____ 
______________________ Inside____ Outside____ Both____ 
______________________ Inside____ Outside____ Both____ 
______________________ Inside____ Outside____ Both____ 

International Homestay Agency  - Chico 
www.internationalhomestayagency.net 
Revised 09/06/12   
2 
Family Hobbies and Interests     
___________________________________________________________________     
___________________________________________________________________ 
 
Languages 
What is the primary language spoken in your home? ________________________________ 
Are all members of your family fluent in English? _____________________ 
Do any members of your family speak another language? Yes___   No___  
*If "yes," please indicate which members and which language____________________ 
 
Religious Affiliation 
Our family is_________________________________Denomination:____________________ 
Decline to state____ 
 
We attend services: Weekly___ Monthly____ Occasionally____ Seldom____ Never_____ 
 
Health Conditions 
Do any members of your family have any disabilities or health conditions that a student  
should be made aware of?______________________________________________________ 
 
Why would your family be interested in hosting an international student?  
_____________________________________________________________________ 
_____________________________________________________________________ 
_____________________________________________________________________ 
 
How did you hear about Int’l Homestay Agency program? ____________________ 
_____________________________________________________________________ 
 
References 
Please provide the names, addresses, and telephone numbers of two persons available to  
provide The Agency with a reference on your family with regards to hosting international students. 
 
___________________________________________ ____________________________ 
(Name)       (Telephone)  
___________________________________________________________________________ 
(Street Address)      (City)    (Zip)   
 
_______________________________________      ____ 
(Best hours to call)      (Relationship to you)  
====================================================================== 
 
____________________________________________  ____________________________ 
(Name)        (Telephone)  
___________________________________________________________________________ 
(Street Address)      (City)   (Zip)   
 
_______________________________________  ____________________________ 
(Best hours to call)      (Relationship to you)  

International Homestay Agency  - Chico 
www.internationalhomestayagency.net 
Revised 09/06/12   
3 
Placement Information 
 
Prefer to host Female___ Male___ Either___ 
Are able to host: (1) student___   (1-2) students ___ (2 or more) students only___ 
 
Nationality 
 
Prefer to host student(s) from_________________________________________________ 
 
Prefer not to host student(s) from______________________________________________ 
 
No preference______ 
 
Accommodations-check the features below that are found in your home  
 
Does your home have:   
Basketball Hoop? (Y/N) _____  
Swimming Pool? (Y/N) ______ 
*High Speed Wireless Internet?  Yes___   No___ 
 If Yes, great! 
 If No, when will you be equipped with wireless high speed internet?  ___________ 
 * Students require high speed wireless internet accessibility in the home 
Room #1            
Single room___    Double room___    Roommate___    Desk___    Study lamp___  
 
Chest of drawers___    Closet space ___    Towels___   Other_______________________ 
_________________________________________________________________________ 
 
Room #2            
Single room___    Double room___    Roommate___    Desk___    Study lamp___  
 
Chest of drawers___    Closet space ___    Towels___    Other _______________________ 
__________________________________________________________________ 
 
Meals 
The family must provide food for all meals. The family will prepare dinner or make other 
 Arrangements: 
Breakfast will be prepared by:   Family___ Student___ 
Lunch will be prepared by:    Family___       Student ___ 
 
Laundry 
Laundry will be done by:   Family___ Student___ 
Student may use family's:   Washer___     Dryer ___ 
 
Transportation: The family will provide transportation to and from school. 
Is there a bus stop nearby?       Yes___           No___ 
If the student has a car, is there parking space available?    Yes___ No___