Host Information Form Foreign Exchange Students Page 2
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5DOUGLAS COUNTY SCHOOL DISTRICT RE-1
HOST INFORMATION FORM
FOREIGN EXCHANGE STUDENTS
STUDENT INFORMATION
STUDENT'S NAME:
DATE OF BIRTH:
COUNTRY:
DCSD SCHOOL:
GRADE:
NAME OF PARENTS
FOREIGN EXCHANGE ORGANIZATION (FEO) INFORMATION
FEO NAME:
FEO ADDRESS:
FEO CONTACT:
PHONE NUMBER:
EMAIL:
HOST(S) INFORMATION
HOST(S):
ADDRESS:
PHONE:
EMAIL:
In connection with this Request, I make the following representations:
1. The care and custody of the student listed above has been temporarily placed in my control by a Power
of Attorney executed by the foreign exchange student's parents through the indicated Foreign Exchange
Organization's Power of Attorney.
2. I am a resident of the Douglas County School District RE-1.
10/02/12
Page 1 of 4
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