Friendship Family Interest Form

* = required field

Why do you and your family want to participate in the Friendship Family program*

How do you think your student will benefit by becoming part of your family*

Last name:*

First name(s):*

Home Address:*

City:*

State:*

Zip code:*

Phone Number:*

Best time to reach you at home:*

E-mail address:*

Number of family members participating in the program:*

Have your previously participated in Luther's Friendship Family Program?*

	Yes
	No

Preferences:

I'd prefer a student who is:

I would be willing to outreach to my student (please check all that apply)

Please select the top 3 activities that are important to you and your family*

If Other please specify

Do you have any pets? if yes please specify

We/I would be interested in hosting more than one international student.

	Yes
	No

How did you hear about the program

Have you ever been convicted of anything other than a traffic violation?*

	Yes
	No

If Yes, please specify or contact the Center for Intercultural Engagement and Student Success

Tarbabypre

(Please don't fill in this field.)

Tarbaby

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Noturl

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Antlion

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	During Friendship Family events
	During Fall Break
	During Winter Break
	During Spring Break
	For holiday dinners

	Cooking
	Sports
	Arts
	Shopping
	Religion
	Relaxing at home
	Outdoor activities
	Enjoying a good meal
	Going out for coffee or ice cream
	Other (please see below)

An Iowa College in the Liberal Arts Tradition