Fillable ISHP Host Family Application And Picture Form (Elgin Community College)

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ISHP Host Family Application And Picture Form (Elgin Community College)

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Elgin Community College
International Student Homestay Program
Host Family Application
Page 2 of 15
Elgin Community College International Student Homestay Program
Host Family Application
Thank you for your interest in becoming a host family for an international student attending Elgin
Community College. Elgin Community College is pleased to offer the International Student Homestay
Program to international students enrolled full-time at ECC in a degree program, the Intensive English
Program, or an ECC sponsored Special Program. Hosting an international student is a unique
opportunity for individuals to connect with the global community.
Applying for the International Student Homestay
Program as a Host Family
To apply, you must complete all items on the following checklist:
1. Read, complete, and sign the Host Family Application for the ECC International Student
Homestay Program.
2. Read, complete, and sign the Program Information, Policies, and Agreement for Host Families
for the ECC International Student Homestay Program.
3. Submit a letter of introduction describing your family.
4. Submit a copy of your homeowners/renter’s insurance policy.
5. Submit a copy of your automobile insurance policy and copies of valid driver’s licenses for all
licensed drivers living in the host home.
6. Submit your application by email to nescobar@elgin.edu, by fax to 847-214-7785, or by mail
to:
Elgin Community College
Center for International Education and Programs
1700 Spartan Drive
Elgin, IL 60123
7. Potential host families will be required to complete a background check immediately before
a placement is anticipated to be made. Payment for the background check is made directly to
the agency conducting the background check. ECC reimburses all hosts for the cost of the
background checks. Background checks are required for every potential host and any adult
over the age of 18 living in the host’s home, including children away at college who return
home for vacations, holidays, etc.
The homestay app
lication will only be processed once all above materials are received by the ECC Center
for International Education and Programs. Host applications are accepted throughout the year. The
Homestay Program does not guarantee a homestay placement.
Page 3 of 15
Please complete all fields of this application. Incomplete applications will not be processed and will
delay the potential placement of a student in your home.
Host Information
Date of application: _________________
(month/day/year)
Desired placement date: _________________
(month/day/year)
Primary Host Family Surname: ____________________________________________________________
Current address ______________________________________________________________________ :
House Number and Street
_____________________________________________________________________________________
City/Town State Zip Code
Home phone: _______________________________ _____________________________ Mobile phone:
Email address: _________________________________________________________________________
Primary Host #1 Information (this should be completed by the primary contact for the homestay
application):
Surname: _____________________________________________________________________________
First Name/Given Name: __________________________________ _________________ Middle Name:
Name you wish to be called: _______________________________ Gender:
Male Female
Date of birth: ______________
(month/day/year)
Age: _____ May we provide your age to poten
tial stu
dents? Yes No
Marital Status:
Single Married Common Law Separated Divorced Widowed
Other: ____________________________
Occupation: __________________________________________________________________________
Mobile phone: _____________________________ Office phone: ______________________________
Native language: ______________________________ ____________________ Other languages spoken:
Primary Hos
t #2 Information (this should be completed by the se
condary co
ntact for the homestay
application):
Surname: _____________________________________________________________________________
First Name/Given Name:
__________________________________ Middle Name: __________________
Name you wish to be called: _______________________________ Gender: Male Female
Date of birth:
______________
(month/day/year)
Age: _____ May we provide your age to potential students? Yes No
Page 4 of 15
Marital Status
:
Single Married Common Law Separated Divorced Widowed
Other: ____________________________
Occupation: __________________________________________________________________________
Mobile phone: _____________________________ Office phone: ______________________________
Native language: ______________________________ Other languages spoken: ____________________
Family Members
Please provide th
e following information about other individuals living
in t
he household:
Adults (age 18 and older
)
Surname
First Name
Date of Birth
Gender
Profession
Relation to Host
Children (age 17 and under)
Surname
First Name
Date of Birth
Relation to Host
Emergency Contact:
Name: _______________________________________________________________________________
Mobile phone: _________________________________________ Home phone: ___________________
How did you hear about the International Student Homestay Program?
_____________________________________________________________________________________
_____________________________________________________________________________________
General Housing Information
All homestay options are required to provide two meals (breakfast and dinner) daily. Please indicate the
type of homestay placement(s) you are willing to offer:
Short-term (30 days)* without transportation: $600 per month
Short-term (30 days)* with transportation to and from school: $800 per month
Long-term (one semester/16 weeks) without transportation: $600 per month
Long-term (one semester/16 weeks)* with transportation to and from school: $800 per month
Special Programs with transportation: $27 per day
Page 5 of 15
*Please note there is a o
ne month/30 day minimum for hosting a student (this does not apply to
students enrolled in a Special Program). If you host for the short-term (30 day) homestay option, the
student will need to secure housing beyond the 30 day period (such as a local apartment or flat). In
extenuating circumstances, you may offer an extension of the short-term homestay with the approval of
the Homestay Coordinator. A student arriving mid-semester who chooses the long-term homestay
option will be placed in the homestay for the number of weeks remaining in the semester.
Many host families may be willing to host a student long-term but require assistance with hosting a
student when they are away on vacation. Would you be willing to host a student for 1-14 days while a
student’s assigned host family is out of town?
Yes No If yes, please specify any restrictions (such as specific holidays, days of the week, etc.):
_____________________________________________________________________________________
_________________________________________________________________________
____________
How long would you like to host
a student?
1 semester 2 semesters Short-term (30 days)
Holidays/Vacations/Emergencies Special Programs No Preference
Gender Preference: Male Female No Preferenc
e
Are you will to host a student who is age 15 -17? Yes No
Are you willing to host a non-traditional/adult student or short-term scholar? Yes No
Describe the type of host home. Single family home Apartment/Condo Townhouse
Other: _________________________________________________________________
Are you able to provide the student with his/her own room? Yes No
Students in the homestay program are allowed to share a room with another student in the program.
Are you able to accommodate more than one student? Yes No
Will the student share a bathroom with anyone? Yes No If yes, with whom? _
_________________
Please describe the laundry facilities to which the student has access.
_____________________________________________________________________________________
____________________________________________________________________________________
Do any members in your household smoke?
May the student smoke in your home?
If no, will you permit smoking outside of your home? Yes No
If the student is at least 21 years of age, may he/she drink alcohol in your home?
Yes No
Yes
No
Yes
No
Page 6 of 15
Do any me
mbers of your household follow particular diets? Yes No If yes, please specify:
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any
pets?
Yes No
If yes, please provide the following information:
Type of Animal
Breed
Name
Age
Indoor/Outdoor
Animal
Do any of your pe
ts have a bite history or could they be considered vicious or aggressive?
Yes No
If yes, please provide details:
___________________________________________________
__________________________________
_____________________________________________________________________________________
Do you plan to c
ook breakfast and dinner for the student?
Yes No No Preference
Do you plan to eat breakfast and/or dinner with the student?
Yes No No Preference
Would you accept a student who plans to cook their own meals most of the time?
Yes No No Preference
Arrival Information
Most international students will require airport pickup. We strongly encourage you to provide airport
pickup service from Chicago O’Hare International Airport or Chicago Midway International Airport, but
the decision is ultimately yours. The fee for airport pickup from Chicago O’Hare is $50.00; the fee for
airport pickup from Chicago Midway is $75.00. This fee is payable directly to you by the student along
with the first month’s homestay fee and security deposit. If airport pickup is requested, you will meet
the student at his/her flight’s baggage claim area with a sign with his/her name on it. We encourage
students to arrive on a weekend. Flight information must be received 14 days prior to the student’s
arrival date for airport pickup to be arranged and finalized.
Are you willing to provide airport pickup to Chicago O’Hare International Airport or Chicago Midway
International Airport? Yes No
Do you have any days/times you are unable to provide airport pickup? Yes No If yes, please
specify:______________________________________________________________________________
____________________________________________________________________________________
_
Page 7 of 15
Transportation
Who will be responsible for transporting the student to and from ECC?
Name: _______________________________________________________________________________
Age: _________________ Driver’s License Number: ______________________________________
Issuing State: _____________________________
_____ Expiration Date: ________________________
_
How many miles is your home from Elgin Community College’s m
ain campus?
_____________________
Is there a bus stop near your hom
e?
Yes No If yes, please specify: __________________________
Will you host a student who currently owns or plans to purchase a car? Yes No
If yes, please describe parking availability and/or restrictions:
____________________________________________________________________________________
Are yo
u willing to help the student in finding a car to buy if requested? Yes No
Are you willing to help the student apply for a driver’s license?
Yes No
Do you understand that ECC does not provide individual transport to and from the campus?
Yes No Initial here to indicate your understanding of these terms. ________________________
Lifestyle and Interests
What are your expectation
s in hosting an international student?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe a typical day in your household.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever hosted in your home a person from another country? If yes, please explain.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you ever trave
led to another country? If yes, please explain.
Page 8 of 15
Please describe the type of special interests and/or hobbies that you and/or your family enjoy.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What types of sites and experiences do you wis
h
to share with the student?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What religion do you practice (if any)? _____________________________________________________
Are you willing to host a student who practices a different religion than your own? Yes No
Would you decline placement of a student of a specific religion?
Yes No If yes, please specify:
_____________________________________________________________________________________
_______
______________________________________________________________________________
_____________________________________________________________________________________
Would you decline placement of a student from a specific country/region?
Yes No
If yes, please specify:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Would you be comfortable hosting a student who is gay, lesbian, bi-sexual, or transgender?
Yes No
Please list any medical or physical conditions yo
u
or members of your household have that may impact
your ability to host a student.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any medications that you or mem
be
rs of your household are currently taking that may impact
your ability to host a student.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Can you accommodate a student who needs special accommodations to live independently in a
homestay (for instance: a student who uses a wheelchair)?
Yes No
If yes, please explain:
______________________________________________________
_______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you or any members of your household have any psychological or emotional conditions that would
affect your participation as a host family?
Page 9 of 15
Yes
No If yes, please explain:
_____________________________________________________________________________________
_____________________________
________________________________________________________
_____________________________________________________________________________________
What questions or concerns do you have about hosting a student?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Host Family Screening Information
All host family applicants are required to complete the following section in full. Failure to disclose
pertinent information may result in a match not being made between a host applicant and a homestay
student. All adults aged 18 and over who may reside in the home during the student’s stay are required
to undergo a background check before hosting an international student.
Has any person living in your household ever been convicted of a criminal offense? (Minor traffic
violations can be excluded. Please note that a DUI/DWI conviction is not considered a traffic violation).
Yes No If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Has the Department of Children and Family Services or its equivalent ever made a finding against a
member of your household?
Yes No If yes, please explain:
_____________________________________________________________________________________
______________________
_______________________________________________________________
_____________________________________________________________________________________
Do you or any member of your household own a firearm? No Yes If yes, please describe storage
and safety precautions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you or any member of your household have a h
istory of alcohol, drug, or sexual abuse?
Yes
No If yes, please explain:
_____________________________________________________________________________________
______________________
_______________________________________________________________
_____________________________________________________________________________________
Page 10 of 15
Please list three references who have known you (and members of your household if applicable) for at
least two years.
Reference Name Relationship to Host Phone Years Known
____________________________________________________________
_________________________
_______
______________________________________________________________________________
_____________________________________________________________________________________
A personal interview is required of all household members. Additionally, all potential host homes are
screened by the Homestay Coordinator in a v
isit to the home. Please indicate your understanding of
these terms by initialing here. ___________
Additional Information
Please note an
y additional information you wis
h t
o include with your application.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Although all attempts are made to promote a positive and safe homestay experience, Elgin Community
College is not responsible for the lifestyle, schedule, behavior, philosophy, religious affiliation or
occupation of the student. By signing below, I certify that the information I have provided in this
application is true and accurate; that I have familiarized myself with the ECC International Student
Homestay Program by reading all the information contained within the Homestay Application and
Agreement; that I understand the application process will include a home visit, an interview conducted
by the ECC Homestay Coordinator and inquiries about me and members of my household if applicable;
and that all members of my household aged 18 or older must undergo a background check. Additionally,
I certify I give my permission for my housing information to be released to the student’s parents,
guardian and/or agent. I understand that once I am assigned a homestay student, I am obligated to
participate in the homestay for the duration of time as specified in the Homestay Agreement. I have
read and understand the Host Family Code of Conduct, and I agree to abide by the code of conduct it
describes when hosting a student.
________________________________
Signature of Host #1:_________________________________ Date: ______
____________________
Signature of Host #2:_ Date: __________________________
Signature of Adults Living in the Home (age
18 and older)
Signature: _________________________________________
_________________________________________
_________________________________________
Date: __________________________
Signature: Date:
__________________________
Signature: Date
: __________________________
Page 11 of 15
Elgin Community College International Student Homestay Program
Host Family Picture Form
Please complete the following form. All pictures should be recent photographs taken within the last
12 months. All pictures become the property of Elgin Community College and will not be returned to
prospective host families. ECC will not share your information or photographs without your prior
written consent. Photographs may also be emailed to nescobar@elgin.edu.
Our Family (Please provide a group photo of your family (including pets) and provide names of all
individuals in the photo):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Our Home:
Page 12 of 15
Our Neighborhood (Please provide up to three photos of your neighborhood):
Page 13 of 15
Student Bedroom #1
Student Bedroom #2 (If applicable)
Page 14 of 15
Bathroom
Other (please specify):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Page 15 of 15
Elgin Community College International Student Homestay Program
Directory Consent Form
The International Student Homestay Program distributes a host family directory at the beginning of each
semester containing the information of current hosts. The directory is beneficial when host families
coordinate joint activities.
_______ I would like Elgin Community College to include the following information in the International
Student Homestay Program Directory
:
_______ Address
_______ Phone numbers
(home and cell)
_______ Email address
_______ Do not include my family in the International Student Homestay Program Directory.
Name of Host #1: __________________________
__________
Signature of Host #1: _______
_____________________________ Date: ____________________
Name of Host #2: __________________
__________________
Signature of Host #2: _______
_____________________________ Date:
____________________
This form must accompany your Program Information, Policies, and Agreement for Host Families for
the ECC International Student Homestay Program in order for your application to be processed.
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ISHP Host Family Application And Picture Form (Elgin Community College)

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Completed 25 July 2020

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