Youth Exchange Program Electronic Host Family Application

LIONS CLUBS INTERNATIONAL MULTIPLE DISTRICT 19 Youth Exchange Program – Electronic Host Family Application Host Family Data Last First Name(s): Name(s):

Street: P.O. Box:

State/ Postal/Zip City: Country: Province: Code: Cell Work Home Phone: Phone: Phone:

E-Mail: Note: The street address is required, add any mailing address required. Please give an E-mail address.

Names & ages of children at home:

o you have pets? Do you have pets? Yes No Does anyone in the home smoke? Yes No

Occupationa of Head of Family: Family Religion:

Preferencea of Exchange Country: (1) (2) (3)

a Preferred Hosting Period: First Second Either

st Preferreda Dates (1 Choice): From: To:

Preferred Dates (2nd Choice): From: To:

a Preferred Gender: Male Female Either Preferred Age:

aFamily Activities / Special Interests:

Usuala climate during exchange Period: Cool Warm Hot Sunny Rain Snow

DoWilla you one have parent pets? be home during the Is applicant or period of the home stay? Yes No spouse a Lion? Yes No

If at least one parent is not at home during the stay, please indicate if another responsible person will be in the home. a The youths should not be alone for long periods of time.

Responsible adult at home:

X Host Family Signature: Date: X Host Family Signature:

HostA Family E-App Revision 2 – February 27, 2014 MD-19 Host Family Application – Page 1 of 2 LIONS CLUBS INTERNATIONAL MULTIPLE DISTRICT 19 Youth Exchange Program – Electronic Host Family Application

Sponsoring Lions Club:

The host family will provide room, board and local transportation. The Club can assist with incidental expenses. Name of Sponsoring Club: District & Zone:

Population of Community: Character (Industrial, Etc.):

Date: X Club Signature:

Title: Note: Club signature should be President or Secretary to sponsor a Host Family.

Club Mailing Address: Phone Number of above: City: State/Province: Country: Postal/Zip Code: E-mail Address: Club website:

X Signature of Multiple Date: District YEP Coordinator:

Application Mailing / E-Mailing Instructions: E-mail completed applications to: [email protected] In Canada, Mail completed application to: Lion Ron Silver, 2826 Gook Street, Quesnel, BC V2J 4J1 Canada In USA, Mail completed application to: Lion Kathy Schumer, 1415 – 84th St. SE #145, Everett, WA 98208 U.S.A.

Note: Complete Application in singular, this form can be photocopied by the YEP representative. Family photo(s) should be attached or enclosed.

Host Family E-App Revision 2 – February 27, 2014

MD-19 Host Family Application – Page 2 of 2