<p> LIONS CLUBS INTERNATIONAL MULTIPLE DISTRICT 19 Youth Exchange Program – Electronic Host Family Application Host Family Data Last First Name(s): Name(s):</p><p>Street: P.O. Box:</p><p>State/ Postal/Zip City: Country: Province: Code: Cell Work Home Phone: Phone: Phone:</p><p>E-Mail: Note: The street address is required, add any mailing address required. Please give an E-mail address.</p><p>Names & ages of children at home: </p><p> o you have pets? Do you have pets? Yes No Does anyone in the home smoke? Yes No</p><p>Occupationa of Head of Family: Family Religion:</p><p>Preferencea of Exchange Country: (1) (2) (3)</p><p> a Preferred Hosting Period: First Second Either</p><p> st Preferreda Dates (1 Choice): From: To:</p><p>Preferred Dates (2nd Choice): From: To:</p><p> a Preferred Gender: Male Female Either Preferred Age:</p><p> aFamily Activities / Special Interests:</p><p>Usuala climate during exchange Period: Cool Warm Hot Sunny Rain Snow</p><p>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</p><p>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.</p><p>Responsible adult at home:</p><p>X Host Family Signature: Date: X Host Family Signature:</p><p>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 </p><p>Sponsoring Lions Club:</p><p>The host family will provide room, board and local transportation. The Club can assist with incidental expenses. Name of Sponsoring Club: District & Zone:</p><p>Population of Community: Character (Industrial, Etc.): </p><p>Date: X Club Signature:</p><p>Title: Note: Club signature should be President or Secretary to sponsor a Host Family.</p><p>Club Mailing Address: Phone Number of above: City: State/Province: Country: Postal/Zip Code: E-mail Address: Club website:</p><p>X Signature of Multiple Date: District YEP Coordinator:</p><p>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.</p><p>Note: Complete Application in singular, this form can be photocopied by the YEP representative. Family photo(s) should be attached or enclosed.</p><p>Host Family E-App Revision 2 – February 27, 2014</p><p>MD-19 Host Family Application – Page 2 of 2 </p>