DISTRICT A-1 LIONS INTERNATIONAL YOUTH EXCHANGE	

Host Family Application
Police Check policy: please see A1 web site at wwwa1lions.ca/Policy-PoliceClearance.pdf
Hosting preference:  June 28 – July 09	July 09 – 19 	
Name:	Address  	
City: 	  PC:	
Phone:  	  Email:	
Occupations: Husband:	Wife: 	
Is the husband a Lion: 	Yes___ No___ 	Club Name: 	
Is the wife a Lion/Lioness: 	Yes___ No___ 	Club Name: 	
Name, age and sex of children living at home:
Name: 	
Name: 	
Name: 	
Name: 	
Languages spoken in the home: 	
Religious affiliation/preference: 	
Family interests, pastime: 	
Is your home located: urban area 	 rural area 	small town 	
Population of town/City 	 Pets in the home:	
Is there smoking in the home? Yes ______ no ________
Previous hosting experience (include details) 	
	
HOST FAMILY PREFERENCE
We would prefer 	one student 	two students 	boy 	girl	
Age  	smoker 	non-smoker 	
Nationality and/or other preference: 	
We confirm that a parent or other responsible adult will remain at home during the visitors stay.
In fairness to the youth and other host family(ies) involved, we understand we must relinquish contact with the youth while he or she is visiting with another host family.

Signature of host
Parents 	date