Page 1 of 2

Personal Reference for Host Families

We will use this reference to determine the host family's suitability to host an exchange visitor in their home. This reference cannot be completed by a relative.

Host Family Name

Referee Name

Referee Address

Referee Phone Number

Referee Email

How do you know the Host Family?

How long have you known the Host Family?

Why would this applicant provide a good environment for a visiting foreign national?

Please describe any unusual conditions you have witnessed in the home.

Have you ever been aware of any alcoholism, abuse, or violence in the home?

Do you feel that the Host Family could treat a foreign national living in the home as an equal?

Additional comments

Please let us know if you have other information that would help us to make the decision whether or not to place an au pair in the Host Family's home.

Signature

I, the referee, confirm that I have used my own words and opinions in completing this form.

Signature