Host Family Application Form 2018

Full Name*

First NameLast Name

Address*

Street Address

PO Box if applicable

CityProvince

Postal Code

Home Phone Number (if applicable)

Cell Phone Number

Work Phone Number

E-mail address(es)*

example@example.com

What is the population of your town/city?*

Our home is in a(n) _____ area:*

UrbanRural

How did you hear about Northern Youth Abroad?*

Why would you like to be an NYA Host Family?*

Please list yourself and any other adult caregivers in your household.*

	Caregiver(s) Name	Gender	Age	Occupation
1.
2.
3.

Please indicate your marital status:*

Please list all the children in your family.

	Children's Names	Gender	Age	Lives at home?
1.
2.
3.
4.
5.

Please list any other people living in your home.

	Full Name	Gender	Age	Relationship to the family
1.
2.
3.

What languages are spoken in your home?*

Do you have any pets? If so, how many?*

Describe your family's typical summer weekday. Include details such as work schedules, extra-curricular activities, and any other regular commitments.*

Describe your family's typical summer weekend.*

The Participants will spend approximately 35 hours per week at their work placements. Ideally, they will work 7 hours per day and have evenings and weekends free. How much time are you able to commit to the Participants during their free hours?*

Northern Youth Abroad Participants sign behaviour guidelines before participating - one of which is to commit to not drinking alcohol or consuming drugs at any point of the program, even if of legal age. While we do not expect host families to do the same, we are wondering what the intake of alcohol and cannabis is like in your home:*

	Never	Occasional	Regular	Daily
Alcohol
Cannabis

Any additional comments related to drinking/drug use?

Please list any connections you may have to Northern Canada.*

Have you hosted before?*

YesNo

If yes, please describe:

Have any family members lived or travelled abroad or had cross-cultural experiences? If so, please describe who, where, when, etc.*

Please list any clubs/organizations, hobbies, or special interests your family members belong to/have:*

Is your family religious?*

If you attend a religious service, is it important that the Participants attend with you?*

YesDoes not matterNot applicable

Please describe your community. Include information about population, location, amenities, access to public transportation, and local attractions.*

NYA Staff Members are responsible for setting up volunteering work placements for the Participants. Do you have any suggestions of possible work placements in your area?*

Is public transportation available for Participants to get to and from their work placements?*

YesNo

Do you have a vehicle?*

YesNo

Do you have a preference between hosting females or males?*

Prefer femalesPrefer malesNo preferenceOpen to 2SLGBTQ+ youth

Will the participants each have their own rooms?*

YesNo (Sharing a room is fine, but the youth must each have his/her own bed)

Do you have internet in your home?*

YesNo

Would you accept Participants who are smokers? Participants will be asked to only smoke outside the house.*

Yes, I will accept smokersI prefer non-smokers, but will accept smokersNo, I will not accept smokers

*Please note: one notable difference between Northern Canada and Southern Canada is that smoking is still very common and widely accepted. NYA is committed to supporting Participants in making healthy lifestyle choices and incorporates a smoking cessation session into our Orientation. However, inevitably each year a large proportion of our Participants are smokers. Please be aware that selecting non-smokers only may result in us not being able to place Participants in your home.

Many Northern youth are accustomed to eating meat or fish daily in their diet. Part of the youths' experience will be adjusting to some new foods and different types of meals. However, would there be reasons (vegetarian, religious, health, etc) why meat would NOT be available in your home?*

YesNo

Will your Participants have the opportunity to meet other teenagers in the community (ie through neighbours, family friends, sports teams, etc?)*

YesNoUnsure

Will your family be spending any time away during the youth's stay this summer? If so, please indicate dates and where you will be staying. If you do not know at this time, please inform NYA Staff Members when your plans are made.

What type of youth would fit in best with your home and family?*

This is a volunteer opportunity. However, NYA provides a stipend of $350/week to help with some of the costs of food/utilities, with additional funds available upon request. Would hosting put a financial strain on you?*

YesSomewhatNo

Please list any questions you have or add anything you would like to expand upon.

Please provide contact information below for 3 personal references (friends, colleagues, neighbours, etc). These references will be contacted for a brief phone interview in support of your application. Please do not use family members as references.*

	Full Name	Relationship to Applicant	Phone #	Email Address	Best Way & Time to Contact
1.
2.
3.

Successful applicants will be asked to participate in a video/phone interview after the application deadline. Selected families will receive a Host Family Handbook and will have regular contact with the NYA Program Staff before and during the summer placement. Please note: upon selection, all Host Family Members aged 18 and older must submit Vulnerable Sector Checks to NYA (completed within the previous 12 months). If you have any questions, please contact the NYA Office.

Kira Zanyk Davey
Program Officer
Northern Youth Abroad
kira@nya.ca
308-311 Richmond Road
Ottawa, ON, K1Z 6X3
Phone: 613-232-9989
Fax: 613-232-2121
Toll-free: 1-866-212-2307

Host Family Application Form

Contact Information

Your Family

Your Connection to Northern Canada

Cross-Cultural Experience

Family Interests

Your Community

Additional Information

Next Steps