HOST FAMILY APPLICATION FORM

  • Host Family Application Form

    Include with completed application form:

    An image of your family with a short letter to the student about your family.

    An image of the room where the student will be sleeping.

    Two references that you have known for at least 2 years that are not family members.

  • NameSurnameDate of BirthSchoolGender 
  • Drop files here or
    Max. file size: 512 MB.
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    • First Host Parent

    • Second Host Parent

    • NameAgeDate of BirthSchool/OccupationLiving at home? 
    • NameAgeDate of BirthSchool/OccupationLiving at home? 
    • HIGH SCHOOL INFORMATION (For students planning to attend a school near your home.)

    • NamePhone numberEmail Address 
    • Rules For Visiting Students

      These rules are enforced in all Pursue Languages programs and have been established as minimum standards of participant conduct and any infraction may result in immediate return of student to his/her home country. Each student and his or her parent(s) or legal guardian(s) must acknowledge that they understand and agree to these rules prior to the student’s final program acceptance:

      Student Expectations (For Your General Knowledge)

      • Students must always respect and uphold host family rules regarding curfew, household chores and internet use. Activities, including inviting guests to the host family’s home and dating, must be approved by the host family.

      • Any and all use, purchase or possession of alcohol, drugs, tobacco or harmful controlled substances is prohibited.

      • Handling a gun of any kind or a bow and arrow, is forbidden. The only exception is if you are in an archery class under the guidance of an authorized school instructor.

      • All activities must be approved by your host parents and students must always advise host parents of their whereabouts and when they will return home.

      • Students are expected to obey all local, state and federal laws. Failure to do so will result in disciplinary action.

      Expectations for Host Families

      • In compliance with United States Department of State “Regulations Governing Exchange Visitors Programs.” Pursue Languages requires all adults over the age of 18 years who will permanently and/or temporarily reside in your home/on premises during the exchange submit to a criminal background check and complete and sign the attached authorization form.

      In addition, Pursue Languages may request to send an agent to your home for inspection before and or during the students stay.

      • Host Family members may not offer alcohol, drugs, tobacco or harmful controlled substances as it is prohibited for all students.

      • Offering the use or handling of gun of any kind or a bow and arrow, is forbidden. The only exception is if students are in an archery class under the guidance of an authorized school instructor.

      • We prefer that students have their own room if not students may share a room with a member of the family but they must be of the same sex. However, they must be provided with their own bed (air beds are not acceptable)

      • A member of the family must meet the student at a local pickup point. (if the student is arriving at a local airport, bust station, or train station).

      • Note that family members are not expected to do visiting students' laundry but should kindly assist students that have no experience. •International students may not have the same eating habits, or hygiene standards as you might be accustomed to. We ask that you be understanding with the students and politely speak to them about your concerns. In addition, inform students from the beginning of their stay at your home of all house policies in order to facilitate a smooth stay.

      HOST FAMILY AGREEMENT & CRIMINAL BACKGROUND CHECK AUTHORIZATION FORM

      We agree to host one of Pursue Languages international students, who is unrelated to our family, and agree to attend the host family orientation meeting prior to the student arrival. We have read and understand the above and agree to adhere to them. We agree to cooperate with Pursue Languages and its representatives. We understand that Pursue Languages may not be able to accept all host family applicants and that Pursue Languages has the right to accept and reject host family applicant at any time. We acknowledge that Pursue Languages has the final authority in all decisions concerning discipline, student placements, length of home stay or time in area, and student arrival and departure dates. We realize that failure to cooperate with Pursue Languages may result in the student being removed from our family and relocated or returned to his/her home country. In the event that we are unable or unwilling to continue hosting Pursue Languages international student due to unforeseen circumstances, we shall provide Pursue Languages with adequate notice allowing the program a reasonable period of time to secure a suitable alternative host family.

      We have received the United States Department of State “Regulations Governing Exchange Visitors Programs." (found on page 7 of Host Family Application Form) We understand that to comply with applicable United States Department of State regulations, Pursue Languages requires all adults over the age of 18 years who will permanently and/or temporarily reside in our home/ on premises during the exchange submit to a criminal background check and complete and sign the attached authorization form. Each member of our household, and other adults over age 18 living in our home, has completed, signed and returned a Criminal Background Check Authorization Form. We agree to notify Pursue Languages of any additional person(s) who after the date of our signature on the authorization form may join our household or when a member of our household attains age 18. Each Criminal Background Check Authorization Form will remain in effect during the entire international student's stay with the host family.

      We have received a summary of the Expectations for Pursue Languages students and agree to notify Pursue Languages of any material changes in the status of our family or student, including but not limited to changes in address, employment and criminal arrests. My/our family have adequate resources to host and does not receive needs-based government subsidies for food or housing.

      We (Each of the undersigned “family member”) authorizes Pursue Languages, at any time while a student is a member of the host family, to obtain a report on them in which may include social security verification and criminal history records. This report will not include a credit report. Each family member understands that he/she is entitled to complete and accurate disclosure of the nature and scope of any investigative report of which he/she is the subject upon his/her written request. Each family member hereby releases Pursue Languages their employees and agents, and any and all persons, business entities and governmental agencies that provide information to Pursue Languages from any and all liability resulting from receiving this information.

      Please complete for each host family household. Each member of the host family household 18 years of age and older, as well as any member of the household who will turn eighteen during the international student’s stay must complete and sign this form.

      We certify that all information provided by us is true and correct to the best of our knowledge. Signed and agreed by:

    • Complete NamePhone NumberEmailSS#Date of Birth (MM/DD/YY) 
    • HOST FAMILY MEDIA RELEASE FORM

      I hereby grant Pursue Languages and its representatives permission to use my likeness (and my child's if under 18) in a video and photograph in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Pursue Languages and will not be returned.

      I hereby irrevocably authorize Pursue Languages and its representatives to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Pursue Languages programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness (and my child's if under 18) appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

      I hereby hold harmless and release and forever discharge Pursue Languages and its representatives from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

      I understand that I may decline to give my consent (by not signing this form) and still continue to participate in all Pursue Languages programs and activities without being disadvantaged with respect to those activities.

    • Child #1 NameChild #2 NameChild #3 Name 
    • NameDate 
    • NameDate 
    • NameDate 
    • NameDate 
    • UNITEDSTATESDEPARTMENT OFSTATE PART62—EXCHANGEVISITORPROGRAM

      § 62.25Secondary school students. (a) Purpose. This section governs Department of State designated exchange visitor programs under which foreign secondary school students are afforded the opportunity to study in the United States at accredited public or private secondary schools for an academic semester or an academic year, while living with American host families or residing at accredited U.S. boarding schools. (b) Program sponsor eligibility. Eligibility for designation as a secondary school student exchange visitor program sponsor is limited to organizations: (1) With tax-exempt status as conferred by the Internal Revenue Service pursuant to section 501(c)(3) of the Internal Revenue Code; and (2) Which are United States citizens as such term is defined in § 62.2. (c) Program eligibility. Secondary school student exchange visitor programs designated by the Department of State must: (1) Require all exchange students to be enrolled and participating in a full course of study at an accredited academic institution; (2) Allow entry of exchange students for not less than one academic semester (or quarter equivalency) and not more than two academic semesters (or quarter equivalency) duration; and (3) Ensure that the program is conducted on a U.S. academic calendar year basis, except for students from countries whose academic year is opposite that of the United States. Exchange students may begin an exchange program in the second semester of a U.S. academic year only if specifically permitted to do so, in writing, by the school in which the exchange student is enrolled. In all cases, sponsors must notify both the host family and school prior to the exchange student’s arrival in the United States whether the placement is for an academic semester, an academic year, or a calendar year. (d) Program administration. Sponsors must ensure that all organizational officers, employees, representatives, agents, and volunteers acting on their behalf: (1) Are adequately trained. Sponsors must administer training for local coordinators that specifically includes, at a minimum, instruction in: Conflict resolution; procedures for handling and reporting emergency situations; awareness or knowledge of child safety standards; information on sexual conduct codes; procedures for handling and reporting allegations of sexual misconduct or any other allegations of abuse or neglect; and the criteria to be used to screen potential host families and exercise good judgment when identifying what constitutes suitable host family placements. In addition to their own training, sponsors must ensure that all local coordinators complete the Department of State mandated training module prior to their appointment as a local coordinator or assumption of duties. The Department of State training module will include instruction designed to provide a comprehensive understanding of the Exchange Visitor Program; its public diplomacy objectives; and the Secondary School Student category rules and regulations. Sponsors must demonstrate the individual’s successful completion of all initial training requirements and that annual refresher training is also successfully completed. (2) Are adequately supervised. Sponsors must create and implement organization-specific standard operating procedures for the supervision of local coordinators designed to prevent or deter fraud, abuse, or misconduct in the performance of the duties of these employees/agents/volunteers. They must also have sufficient internal controls to ensure that such employees/agents/volunteers comply with such standard operating procedures. (3) Have been vetted annually through a criminal background check (which must include a search of the Department of Justice’s National Sex Offender Public Registry); (4) Place no exchange student with his or her relatives; (5) Make no exchange student placement beyond 120 miles of the home of the local coordinator authorized to act on the sponsor’s behalf in both routine and emergency matters arising from that exchange student’s participation in the Exchange Visitor Program; (6) Make no monetary payments or other incentives to host families; (7) Provide exchange students with reasonable access to their natural parents and family by telephone and email; (8) Make certain that the exchange student’s government issued documents (ire, passports, Forms DS–2019) are not removed from his/her possession; (9) Conduct the host family orientation after the host family has been fully vetted and accepted; (10) Refrain, without exception, from acting as: (i) Both a host family and a local coordinator or area supervisor for an exchange student; (ii) A host family for one sponsor and a local coordinator for another sponsor; or (iii) A local coordinator for any exchange student over whom he/she has a position of trust or authority such as the student’s teacher or principal. This requirement is not applicable to a boarding school placement. (11) Maintain, at minimum, a monthly schedule of personal contact with the exchange student. The first monthly contact between the local coordinator and the exchange student must be in person. All other contacts may take place in-person, on the phone, or via electronic mail and must be properly documented. The sponsor is responsible for ensuring that issues raised through such contacts are promptly and appropriately addressed. (12) That a sponsor representative other than the local coordinator who recruited, screened and selected the host family visit the exchange student/ host family home within the first or second month following the student’s placement in the home. (13) Maintain, at a minimum, a monthly schedule of personal contact with the host family. At least once during the fall semester and at least once during the spring semester, (ire, twice during the academic year) the contact by the local coordinator with the host family must be in person. All other contacts may take place in person, on the phone, or via electronic mail and must be properly documented. The sponsor is responsible for ensuring the issues raised through such contacts are promptly and appropriately addressed. (14) That host schools are provided contact information for the local organizational representative (including name, direct phone number, and email address), the program sponsor, and the Department’s Office of Designation; and (15) Adhere to all regulatory provisions set forth in this Part and all additional terms and conditions governing program administration that the Department may impose. (e)Student selection. In addition to satisfying the requirements of § 62.10(a), sponsors must ensure that all participants in a designated secondary school student exchange visitor program: (1) Are secondary school students in their home countries who have not completed more than 11 years of primary and secondary study, exclusive of kindergarten; or are at least 15 years of age, but not more than 18 years and six months of age as of the program start date.

      (2) Demonstrate maturity, good character, and scholastic aptitude; and (3) Have not previously participated in an academic year or semester secondary school student exchange program in the United States or attended school in the United States in either F–1 or J–1 visa status. (f)Student enrollment. (1) Sponsors must secure prior written acceptance for the enrollment of any exchange student in a United States public or private secondary school. Such prior acceptance must: (i) Be secured from the school principal or other authorized school administrator of the school or school system that the exchange student will attend; and (ii) Include written arrangements concerning the payment of tuition or waiver there of if applicable. (2) Under no circumstance may a sponsor facilitate the entry into the United States of an exchange student for whom a written school placement has not been secured. (3) Under no circumstance may a sponsor charge a student private school tuition if such arrangements are not finalized in writing prior to the issuance of Form DS–2019. (4) Sponsors must maintain copies of all written acceptances for a minimum of three years and make such documents available for Department of State inspection upon request. (5) Sponsors must provide the school with a translated ‘‘written English language summary’’ of the exchange student’s complete academic course work prior to commencement of school, in addition to any additional documents the school may require. Sponsors must inform the prospective host school of any student who has completed secondary school in his/her home country. (6) Sponsors may not facilitate the enrollment of more than five exchange students in one school unless the school itself has requested, in writing, the placement of more than five students from the sponsor. (7) Upon issuance of a Form DS–2019 to a prospective participant, the sponsor accepts full responsibility for securing a school and host family placement for the student, except in cases of voluntary student withdrawal or visa denial. (g) Student orientation. In addition to the orientation requirements set forth at § 62.10, all sponsors must provide exchange students, prior to their departure from their home countries, with the following information: (1) A summary of all operating procedures, rules, and regulations governing student participation in the exchange visitor program along with a detailed summary of travel arrangements; (2) A copy of the Department’s welcome letter to exchange students; (3) Age and language appropriate information on how to identify and report sexual abuse or exploitation; (4) A detailed profile of the host family with whom the exchange student will be placed. The profile must state whether the host family is either a permanent placement or a temporary arrival family; (5) A detailed profile of the school and community in which the exchange student will be placed. The profile must state whether the student will pay tuition; and (6) An identification card, that lists the exchange student’s name, United States host family placement address and telephone numbers (landline and cellular), sponsor name and main office and emergency telephone numbers, name and telephone numbers (landline and cellular) of the local coordinator and area representative, the telephone number of Department’s Office of Designation, and the Secondary School Student program toll free emergency telephone number. The identification card must also contain the name of the health insurance provider and policy number. Such cards must be corrected, reprinted, and reissued to the student if changes in contact information occur due to a change in the student’s placement. (h) Student extra-curricular activities. Exchange students may participate in school sanctioned and sponsored extracurricular activities, including athletics, if such participation is: (1) Authorized by the local school district in which the student is enrolled; and (2) Authorized by the state authority responsible for determination of athletic eligibility, if applicable. Sponsors shall not knowingly be party to a placement (inclusive of direct placements) based on athletic abilities, whether initiated by a student, a natural or host family, a school, or any other interested party. (3) Any placement in which either the student or the sending organization in the foreign country is party to an arrangement with any other party, including receiving school personnel, whereby the student will attend a particular school or live with a particular host family must be reported to the particular school and the National Federation of State High School Associations prior to the first day of classes. (i) Student employment. Exchange students may not be employed on either a full or part-time basis but may accept sporadic or intermittent employment such as babysitting or yard work. (j) Host family application and selection. Sponsors must adequately screen and select all potential host families and at a minimum must: (1) Provide potential host families with a detailed summary of the Exchange Visitor Program and of their requirements, obligations and commitment to host; (2) Utilize a standard application form developed by the sponsor that includes, at a minimum, all data fields provided in Appendix F, ‘‘Information to be Collected on Secondary School Student Host Family Applications’’. The form must include a statement stating that: ‘‘The income data collected will be used solely for the purposes of determining that the basic needs of the exchange student can be met, including three quality meals and transportation to and from school activities.’’ Such application form must be signed and dated at the time of application by all potential host family applicants. The host family application must be designed to provide a detailed summary and profile of the host family, the physical home environment (to include photographs of the host family home’s exterior and grounds, kitchen, student’s bedroom, bathroom, and family or living room), family composition, and community environment. Exchange students are not permitted to reside with their relatives. (3) Conduct an in-person interview with all family members residing in the home where the student will be living; (4) Ensure that the host family is capable of providing a comfortable and nurturing home environment and that the home is clean and sanitary; that the exchange student’s bedroom contains a separate bed for the student that is neither convertible nor inflatable in nature; and that the student has adequate storage space for clothes and personal belongings, reasonable access to bathroom facilities, study space if not otherwise available in the house and reasonable, unimpeded access to the outside of the house in the event of a fire or similar emergency. An exchange student may share a bedroom, but with no more than one other individual of the same sex. (5) Ensure that the host family has a good reputation and character by securing two personal references from within the community from individuals who are not relatives of the potential host family or representatives of the sponsor (ire, field staff or volunteers), attesting to the host family’s good reputation and character;(6) Ensure that the host family has adequate financial resources to undertake hosting obligations and is not receiving needs-based government subsidies for food or housing; (7) Verify that each member of the host family household 18 years of age and older, as well as any new adult member added to the household, or any member of the host family household who will turn eighteen years of age during the exchange student’s stay in that household, has undergone a criminal background check (which must include a search of the Department of Justice’s National Sex Offender Public Registry); (8) Maintain a record of all documentation on a student’s exchange program, including but not limited to application forms, background checks, evaluations, and interviews, for all selected host families for a period of three years following program completion; and (9) Ensure that a potential single adult host parent without a child in the home undergoes a secondary level review by an organizational representative other than the individual who recruited and selected the applicant. Such secondary review should include demonstrated evidence of the individual’s friends or family who can provide an additional support network for the exchange student and evidence of the individual’s ties to his/her community. Both the exchange student and his or her natural parents must agree in writing in advance of the student’s placement with a single adult host parent without a child in the home. (k) Host family orientation. In addition to the orientation requirements set forth in § 62.10, sponsors must: (1) Inform all host families of the philosophy, rules, and regulations governing the sponsor’s exchange visitor program, including examples of ‘‘best practices’’ developed by the exchange community; (2) Provide all selected host families with a copy of the Department’s letter of appreciation to host families; (3) Provide all selected host families with a copy of Department of State promulgated Exchange Visitor Program regulations; (4) Advise all selected host families of strategies for cross-cultural interaction and conduct workshops to familiarize host families with cultural differences and practices; and (5) Advise host families of their responsibility to inform the sponsor of any and all material changes in the status of the host family or student, including, but not limited to, changes in address, finances, employment and criminal arrests. (l)Host family placement. (1) Sponsors must secure, prior to the student’s departure from his or her home country, a permanent or arrival host family placement for each exchange student participant. Sponsors may not: (i) Facilitate the entry into the United States of an exchange student for whom a host family placement has not been secured; (ii) Place more than one exchange student with a host family without the express prior written consent of the host family, the natural parents, and the students being placed. Under no circumstance may more than two exchange students be placed with a host family, or in the home of a local coordinator, regional coordinator, or volunteer. Sponsors may not place students from the same countries or with the same native languages in a single home. (2) Prior to the student’s departure from his or her home country, sponsors must advise both the exchange student and host family, in writing, of the respective family compositions and backgrounds of each, whether the host family placement is a permanent or arrival placement, and facilitate and encourage the exchange of correspondence between the two. (3) In the event of unforeseen circumstances that necessitate a change of host family placement, the sponsor must document the reason(s) necessitating such change and provide the Department of State with an annual statistical summary reflecting the number and reason(s) for such change in host family placement in the program’s annual report. (m) Advertising and Marketing for the recruitment of host families. In addition to the requirements set forth in § 62.9 in advertising and promoting for host family recruiting, sponsors must: (1) Utilize only promotional materials that professionally, ethically, and accurately reflect the sponsor’s purposes, activities, and sponsorship; (2) Not publicize the need for host families via any public media with announcements, notices, advertisements, etc. that are not sufficiently in advance of the exchange student’s arrival, appeal to public pity or guilt, imply in any way that an exchange student will be denied participation if a host family is not found immediately, or identify photos of individual exchange students and include an appeal for an immediate family; (3) Not promote or recruit for their programs in any way that compromises the privacy, safety or security of participants, families, or schools. Specifically, sponsors shall not include personal student data or contact information (including addresses, phone numbers or email addresses) or photographs of the student on Web sites or in other promotional materials; and (4) Ensure that access to exchange student photographs and personally identifying information, either online or in print form, is only made available to potential host families who have been fully vetted and selected for program participation. Such information, if available online, must also be password protected. (n) Reporting requirements. Along with the annual report required by regulations set forth at §62.15, sponsors must file with the Department of State the following information: (1) Sponsors must immediately report to the Department any incident or allegation involving the actual or alleged sexual exploitation or any other allegations of abuse or neglect of an exchange student. Sponsors must also report such allegations as required by local or state statute or regulation. Failure to report such incidents to the Department and, as required by state law or regulation, to local law enforcement authorities shall be grounds for the suspension and revocation of the sponsor’s Exchange Visitor Program designation; (2) A report of all final academic year and semester program participant placements by August 31 for the upcoming academic year or January 15 for the Spring semester and calendar year. The report must be in the format directed by the Department and must include at a minimum, the exchange student’s full name, Form DS–2019 number (SEVIS ID #), host family placement (current U.S. address), school (site of activity) address, the local coordinator’s name and zip code, and other information the Department may request; and (3) A report of all situations which resulted in the placement of an exchange student with more than one host family or in more than one school. The report must be in a format directed by the Department and include, at a minimum, the exchange student’s full name, Form DS–2019 number (SEVIS ID #), host family placements (current U.S. address), schools (site of activity address), the reason for the change in placement, and the date of the move. This report is due by July 31 for the previous academic school year.


    • Protección de Datos

      Responsable: PURSUE LANGUAGES, S.L
      Finalidad: prestar los servicios que nos ha solicitado, atender sus solicitudes de información y enviarle comunicaciones comerciales.
      Legitimación: interés legítimo y relación contractual entre ambas partes.
      Destinatarios: No se cederán datos a terceros, salvo obligación legal.
      Derechos: podrá ejercitar los derechos de acceso, rectificación, cancelación y oposición, así como los demás derechos que recoge el citado reglamento, para lo cual debe dirigirse a PURSUE LANGUAGES, S.L por correo electrónico a ewambu@pursuelanguages.com
      Procedencia: El propio interesado.
      Para información adicional de segunda capa visitar: https://pursuelanguages.com