Form

IEM Host Family Application
The information you provide on this application will remain confidential and will be used for the sole purpose of arranging a homestay placement of an international student.
To be considered as an IEM host family, you will need to agree to the rules, policies and guidelines set forth by the program, submit required information and agree to a background/criminal check procedure (all members of household 18 and over).

If you have any questions or concerns with the application, please call toll free at: 888-505-8941.

Household Information
Household Information
Does anyone living in your home have a criminal record/convictions or have a case pending? *

Yes No
Is anyone living in your home required to register as a sex offender under Penal Code 290.95? *

Yes No
Do you own any firearms? *

Yes No
How many rooms do you have available? *

1 2 3

Room #1 *

	Yes	No
Is there a comfortable bed for the student? (twin/full size)?
Is there a private bedroom for the student?
Is there a private bathroom for the student?
Is there a closet in the student’s room?
Is there a dresser in the student’s room?
Does the student’s room have a desk/chair/lamp for studying?
Does the student’s room have storage space for other belongings?

Room #2 *

	Yes	No
Is there a comfortable bed for the student? (twin/full size)?
Is there a private bedroom for the student?
Is there a private bathroom for the student?
Is there a closet in the student’s room?
Is there a dresser in the student’s room?
Does the student’s room have a desk/chair/lamp for studying?
Does the student’s room have storage space for other belongings?

Room #3 *

	Yes	No
Is there a comfortable bed for the student? (twin/full size)?
Is there a private bedroom for the student?
Is there a private bathroom for the student?
Is there a closet in the student’s room?
Is there a dresser in the student’s room?
Does the student’s room have a desk/chair/lamp for studying?
Does the student’s room have storage space for other belongings?

Does your home have working smoke detectors? *

Yes No
Is there wireless internet access in your home? *

Yes No
Are there laundry facilities in your home? *

Yes No
ADDITIONAL HOME INFORMATION
Do you own your home? *

Yes No
Do you have home/renter insurance? *

Yes No
Insurance Company Name & Policy #
Is liability insurance included?

Yes No
Does anybody in the house smoke? *

Yes No
If yes, how much and how often?
Does anybody in the home use alcohol? *

Yes No
If yes, how much and how often?
Do you have pets? *

Yes No
If Yes, Indoors/Outdoors? Please give their names and a brief description.
Who is the main cook in the home? *
What type of food do you usually eat at home? *
What are your family hobbies? Interests? *
What activities does your family do on the weekends? *
What languages are spoken in your home? *
Have you ever hosted an international student? *

Yes No
If yes, from which country and how many years? Please describe briefly.
Have any family members lived or traveled abroad? *

Yes No
If yes, in what countries? Please describe briefly.
Do you have any restrictions? Will you accept a student who is a vegetarian? *
Please provide a brief description of your family. This description will be shared with your student prior to arrival to welcome him/her to your family. *

Required Documents
Required Documents
We require you send us copies of valid driver’s licenses (everyone 18+ in the home) as well as a family photo to share with your future student.
You can skip this step now if you are not ready, but your application will not be approved until these items are received. Alternatively you may visit our document upload page or email copies to: homestay@ieducationm.com
Document 1
Document 2
Document 3
Document 4
Document 5

Agreement
Agreement
I/We confirm the accuracy of all information provided in this application. I/We have read the IEM Host Family Handbook and fully understand what is required of us as a host family. I/We agree to follow and enforce all rules, policies and guidelines of the IEM Homestay Program. I/We further understand that IEM is not liable for any loss or damages caused by the hosted international student and confirm that we have adequate liability insurance to protect against such loss or damages. I/We agree to allow IEM to inspect our home prior to student placement and we give our permission for routine home visits by IEM thereafter. I/We further agree to immediately inform IEM if there are any changes to the information provided in this application.

I/We give permission to IEM to perform a criminal background check on each household member aged 18 and older. We are attaching copies of valid California driver's licenses for everyone 18 and older in the home to this application.
Digital Signature *

I understand selecting this button is the legal equivalent of submitting a document signed by hand & confirms my intent to host under the terms above.
Name of Host Parent 1 *
Initials *
Name of Host Parent 2
Initials
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IEM Host Family Application