Survey

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Host Family Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

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

Emergency contact Name

First

Last

Emergency contact Phone

Emergency contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Homeowner's Insurance Co.

Agent's Name and Number

Amount of liability homeowner coverage in force?

Husband's current employer

Husband employer address

Address Line 1

Address Line 2

City

State

Zip Code

How long with employer

Husband position held

Husband work phone

Husband cell phone

Wife's current employer

Wife employer phone

Wife employer address

Address Line 1

Address Line 2

City

State

Zip Code

Wife how long with employer

Wife position held

Phone

homeowner contact sports

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

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?

Does anyone in your family smoke?

Do you have pets?

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

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