Host Ambassador Application


Name(s) ________________________________________   _________________________________________

Address _________________________________________  City___________________  Zip ____________

Phones ( Land)__________________  (Cell)________________   Email ___________________________

Age(s) __________   Gender(s) ___________   Occupation(s)____________________________________

Do you smoke?  __________             Are smokers allowed in your home? __________         Will alcohol be served or allowed in your home? ___________ Could you accommodate a special diet? _____________

Hobbies/Interests _________________________________________________________________________

How would you describe your activity level?  ______sedentary, rarely walk longer than one hour at a time     ______good, but tire easily  _______active/walk for extended periods

Spanish Ability  ________none/poor  _______beginner  _______intermediate  _________fluent

Available Guest Bedrooms & Bed Size(s) __________________________________________________

Are you able to accommodate a single person or a couple?  _______________________________

List all animals you keep inside the home _________________________________________________

Do you have steep stairwells or high steps to get into your vehicle? _______________________

Any home access limitations for a guest with a physical disability? _______________________

How many day activities will you attend with your guest?    1-3        4-6       All    Other____

What days/dates/activities will you need help from a Day Host?  __________________________

Are you able to provide transportation and/or be a Day Host for another host’s guest if needed?  ____________________

Are you able/willing to host a potluck w/other hosts and guest(s)?  ___no  ___small  __large

What do you think makes a good host? ____________________________________________________


Why do you want to host? _________________________________________________________________


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