Amity Host Family Application

If interested in Hosting an Amity Intern, please fill out form below.
The following information will help us match your family with an Amity Intern. PLEASE NOTE that all answers will be kept confidential, and will only be used to match interns with potential families.

Please list names and ages of family members living in your household:
How many members in your family?
Parent #1
First Last
Parent #2
First Last
Family Member #3 - Child
First Last
Family Member #3 - Age
Family Member #3 - Current Grade
Family Member #4 - Child
First Last
Family Member #4 - Age
Family Member #4 - Current Grade
Family Member #5 - Child
First Last
Family Member #5 - Age
Family Member #5 - Current Grade
Family Member #6 - Child
First Last
Family Member #6 - Age
Family Member #6 - Current Grade

Parent #1 Cell Number
Parent #1 Home Number
Parent #1 Work Number
Parent #2 Cell Number
Parent #2 Home Number
Parent #2 Work Number
Parent #1 - Preferred Email Address
Parent #2 - Preferred Email Address
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many hours does each adult work outside the home per week?
Do you have pets?
- Yes
- No
If Yes, how many?
Please list the type of pets in your home:
Are the pets predominantly inside or outside most of the time?
- Inside
- Outside

Does your family follow a restrictive diet plan (i.e. Vegetarian/Vegan/Macrobiotic/Kosher)?
- Yes
- No
If yes, may the Amity Intern cook meat/meat products in your home?
- Yes
- No

Please check one of the following:
- I would prefer to host a MALE Amity Intern
- I would prefer to host a FEMALE Amity Intern
- I have no preference and would host EITHER a male or female Amity Intern
Please check one of the following:
- I would prefer to host an Amity the FIRST half of the school year
- I would prefer to host an Amity the SECOND half of the school year
- I have no preference, and would host EITHER the first or second half of the school year
Would you consider hosting an Amity Intern from SLP Middle School?
- Yes
- No
- Maybe

Will you and/or your family be traveling during the hosting period?
- Yes
- No
If Yes, briefly describe how the Amity Intern will fit into this plan? (Please note that options could include; leaving the intern in your home or the Amity coordinators helping make arrangements for other housing for the intern in your absence):

In general, our family:
- Participates in mostly family/child-centered activities
- Participates in mostly independent activities
Please describe what personality type you think would fit best in your home: (i.e. talkative, quiet, athletic, artistic, etc.)

Please briefly tell us why you are interested in hosting an Amity Intern:
Please describe any other information that you think may help us when determining placement of an Amity Intern in your home:

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