Student Host Family Program Application

Student Name *

Age *

Gender *

Male

Femaie

Phone Number *

Nationality *

Country *

What language(s) can you speak? *

What are you studying? *

Will you need transportation? *

Yes

No

Are there any pets you do not like? If so, which ones & why? *

Any allergies/special dietary needs? *

Yes

No

If yes, please explain:

How often do you want to spend time with a host family? *

Do you want to share your host family with other international student(s)? *

Yes

No

What kind of activities do you like? *

Indoor Activities

Outdoor Activities

Please explain: *

Please provide information about yourself. (hobbies, interests, etc.) *

Western Wyoming Community College is an Equal Opportunity institution, and as such, does not discriminate on the basis of race, color, national origin, sex, age, religion, disability or veteran status in admission or access to, or treatment or employment in, its educational programs or activities. For inquiries concerning Title VI, Title IX, Section 504, ADA , or to access grievance procedures, contact Amy Galley, Western Wyoming Community College, 2500 College Drive, Rock Springs, WY 82901, phone: (307) 382-1645 or Office for Civil Rights, Denver Office, US Department of Education, Cesar E Chavez Memorial Building, Suite 310, 1244 Spear Avenue Blvd., Denver, CO 80204-3582, (303) 844-5695, Fax: (303) 844-4303 or TDD (303) 844-3417 or the Wyoming Labor Standards Department, 1510 East Pershing Blvd., Cheyenne, WY 82002 (307) 777-7261.