Pismo Beach, CA US
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In Home Visit
Host Family Name
Purpose of Visit
First 7 Days and Orientation for New Student
First 30 Day Visit for Returning Student
Student Move In/Out
Did you meet with the student and host separately?
Did you go through AS Orientation Materials with the student?
Please list members of the home who were present
Please describe the condition and your impressions of the home. Are there any concerns?
How is the student's relationship with the family? Does he/she participate with the family? Please explain.
How is the student doing academically? Please explain.
Does the student participate in school sports or activities? Please explain.
Does the student socialize outside of school and the host family home? Please explain.
Did the student express any concerns or issues? If so, please explain.
Did the host family express any concerns or issues? If so, please explain.
Please list any other items discussed that need to be noted.
Please list any changes to the home or host family that should be noted - additional residents, changes to the home, changes to the room, changes to the host family schedule, etc.
Name Of Representative Conducting the Visit
Date of Home Visit
Date Format: MM slash DD slash YYYY
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