Children's Program of Northern Ireland

Your Family

Last Name

Address

City

State

Zip

Primary Phone

Secondary Phone

Best time to call?

Email Address

Host Father

Name

Date of Birth

Occupation

Place of Employment

Work Phone Number

Host Mother

Name

Date of Birth

Occupation

Place of Employment

Work Phone Number

Your Children

Child 1 Name

Child 1 Age

Child 1 Sex

Male

Female

Child 2 Name

Child 2 Age

Child 2 Sex

Male

Female

Child 3 Name

Child 3 Age

Child 3 Sex

Male

Female

Child 4 Name

Child 4 Age

Child 4 Sex

Male

Female

Child 5 Name

Child 5 Age

Child 5 Sex

Male

Female

Child 6 Name

Child 6 Age

Child 6 Sex

Male

Female

Home Environment

Indoor Pets?

Outdoor Pets?

Location Type

City

Metro

Small Town

Farm

Any smokers?

Yes

Special Diets?

Family Religion

Have you previously hosted a child through CPNI?

Yes

Which years?

Irish Child Preference

Male

Female

Have you traveled to Northern Ireland?

Yes

When?

What provisions for the Irish Child’s care will be made while parent(s) are working? Please be specific as to the amount of time needed, type of provider, age, location, etc.*

What provisions for the Irish Child’s care will be made while parent(s) are out socially? Please be specific as to the amount of time needed, type of provider, age, location, etc.*

* CPNI policy states that someone 16 years or older is required to be with the child if parent(s) are away for more than two hours. Someone who is 13 years or older can stay with the child if parent(s) are away for two hours or less. Children are matched with families on the basis of like interests and other factors, such as hobbies and family size.

Personality & Preferences

What organized activites will your family be involved in during the Irish Childs stay?

What other types of activities is your family interested in?

Swimming

Baseball

Cooking

Reading

Hiking

Horseback Riding

Singing/Dancing

Camping/Outdoor

Drawing/Painting

Bicycle Riding

Fishing

Puzzles

Soccer

Tennis

Boating

Video Games

Home Computers

Board Games

Water Skiing

Collecting

Other?

Please help us to match an Irish child to your family by providing information about your family. Suggestions for information: Describe the personalities of ALL family members, activity level of your family, family responsibilities and children’s chores,

What personality and characteristics in the Irish Child would fit in well with your family?

Host Application