Host Family Background Check Form
host family BACKGROUND CHECK form
In accordance with Federal regulations, all adult (18+)residents of a host family home must pass a criminal background check in order to host a J-1 visa high school exchange student. This background check will search only for convictions involving crimes against children, felonies, domestic violence and other violent crimes. Your personal information and the results of your background check will not be shared with your student, IC, or any other third party for any reason. All Host Families will receive an email from Aspect Foundation with instructions onhow to complete background check using a secure online form.
All Host Family background checks should be completed using the online form.
Please only complete this paper form if:
- You do not have access to a computer
- You do not have an email address
- An adult (over 18) member of your household does not have a Social Security Number
Host Family Name:
Street Address (no PO Boxes):
City : State : Zip :
Number of Adults (over 18) living in host home :
Student to be hosted: Student ID: - - -
Host MotherLegalFirst Name: Middle: Last:
Maiden or any other names used:
Host Mother Social Security Number: - - Birthdate (MM/DD/YY) / /
Host Father Legal First Name: Middle: Last:
Any other names used:
Host Father Social Security Number: - - Birth date (MM/DD/YY) / /
Other Adults (over 18) Living in the Home
First Name: Middle: Last:
Any other names used:
Social Security Number: - - Birth date (MM/DD/YY) / /
First Name: Middle: Last:
Any other names used:
Social Security Number: - - Birth date (MM/DD/YY) / /
Has any member of your household ever been charged with a crime? No Yes
If yes, please attach another page explaining the situation.
AverageAnnualIncomeRange (required):
The income data collected will be used solely for the purposes of ensuring that the basic needs of the exchange student can be met, including three quality meals per day and transportation to and from school activities. This information will not be shared with your student or local Aspect Foundation coordinator.
under $25,000 $25,000 - $35,000 $35,000 - $45,000
$45,000 - $55,000 $55,000 - $65,000 $65,000 - $75,000 over $75,000
We, ______by signing below
(Print Names of Adult Family Members Living in Host Home)
do hereby authorize local and/or federal law enforcement officials to disclose criminal history record information to
Aspect Foundation for the purpose of being approved as a host family for an international high school student.
Host Parent#1 Signature______Date______
Host Parent #2 Signature ______Date ______
Other Adult Family Member Signature______Date ______
Other Adult Family Member Signature______Date ______
Please either return this completed form to your IC, or send directly to:
Aspect Foundation, 211 Sutter St, 10th Floor, San Francisco, CA94108
email: fax: 415-228-8051