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Host Family Program

Student Survey

If you have questions about filling out this form, please e-mail Student Life. Thank you.

First name:
Middle:
Last name:
Nickname:
YES, I want to be placed with a Host Family.
NO, I am not interested in having a Host Family.
Address:
Home Phone:
Date of Birth:
Gender:
Male
Female
Parents
MotherFather
Name:
Name:
Address (if different from above):
Address (if different from above):
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Place of Work:
Place of Work:
E-mail Address:
E-mail Address:
High School
High School graduated from:
State
 Graduating class size
Extra Curriular Activities: Mark all activities you participated in during High School:
SportsArtsClubs
Football
Baseball
Basketball
Gymnastics
Tennis
Soccer
Track
Volleyball		 Cheer/Pom
Golf
Swim






 Choir
Band
Orchestra
Pep Band
Jazz Band
Dance
Drama
Debate 		Pep Club
Student Council
FCA
Church Youth Group
Other:



High school honors received (for example, All League, salutatorian):
Leadership Roles (for example, officer of club and/or church youth group, team captain or co-captain):
Work history while in High School (list where you worked and what you did):
Do you have relatives in the Newton area?
Yes
No
If yes, list name and address:
Area in which you want to major:
List the sports, clubs and activities you plan to participate in at Bethel College:
Music interests:
Hobbies:
What are your favorite foods in the following categories? (You may list more than one.)
Meat:

Potatoes:

Breads:

Vegetable:

Fruit:

Dessert:

Snack food:

List any foods that you do NOT like:
Do you wish to attend a church while attending college?
Yes  No  Undecided
If yes, what denominational church would you wish to attend?
Methodist   Catholic   Mennonite   Lutheran   Baptist
Other:
Do you have a car?
Yes  No
Would you like a host family who could help you with maintenance/care of your car?
Yes  No
Would you like a host family to attend your extra-curricular activities and/or substitute for your family at parents’ activities at the college during the year?
Yes  No
What other kinds of assistance would you like to see your host family help you with?
Do you have special medical needs the host family should be aware of and/or give support?
Yes  No
If yes, please explain:
What specifically do you need from a host family?
Are you an international or U.S. citizen?
International  U.S. citizen
If international, what country?
Do you prefer a host family with a similar cultural background?
Yes  No
If yes, which culture do you prefer?
Do you have brother(s)?
Yes  Number:No
Do you have sister(s)?
Yes  Number:No
Sister Name(s) and Age(s):
Brother Name(s) and Age(s):



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300 East 27th Street | North Newton, KS 67117
(316) 283-2500 | 1-800-522-1887
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