Survey

Host Family Name *

Address *

City/Zip *

Home Phone *

Cell Phone

List children's names, ages, and any hobbies/interests *

Emergency contact name *

Emergency contact phone *

Emergency contact Address *

Homeowner's Insurance Co. *

Agent's Name and Number

Amount of liability homeowner coverage in force?

Husband's current employer *

Husband employer address *

How long with employer *

Husband position held *

Husband work phone *

Husband cell phone *

Wife's current employer *

Wife employer phone *

Wife employer address *

Wife how long with employer *

Wife position held

Wife cell phone *

In the last 3 years have you been or are you currently affiliated with any youth, high school, or collegiate sports organization or team? *

If yes, what capacity?

Have you ever been or are you currently affiliated with, employed by, or maintain a consulting relationship with any company that presents itself as a sports agency? *

If yes, please provide complete details of this relationship.

Have you or a member of your household ever pleaded guilty or no contest, or been convicted of a crime? *

If yes, please provide date and details.

Does anyone in your family smoke? *

If yes, whom?

Do you have pets? *

If yes, what kind and how many?

Please provide contact information for three (3) non-family references: *