Host Family Questionnaire– 2008 Week 1

Please complete a separate form for each child that you are hosting.

Family Full Name:

Mailing Address:

Phone:

Your E-mail:

Are you a single parent or a couple?

Number of other children in the family not counting the Summer Miracles Child.

Summer Miracles Child First Name:

Summer Miracles Child Last Name:

Child's Birth Date:

Child's Sex:

City of the Child's Orphanage:

Date Child Entered
Your Home:

1. How did you learn about the Summer Miracles Program and what made you decide to host in this program? 

2. Please describe your first reaction when you saw the child:

About the Child:

3. Describe how the child's personality has emerged over the past week.

4. Child's overall emotional state (please describe briefly and chose one answer below that best reflects your host child's emotional state).

Emotional State (Please Select One):
Unhappy
Rarely Happy
Mostly Happy
Very Happy

5. Child's interaction with family members (please describe briefly and chose one answer below that best reflects child's interaction with family members).

Interaction With Family Members (Please Select One):

Does Not Interact
Has Hard Time Interacting
Interacts Pretty Well
Interacts Very Well  

6. Child's interaction with others (please describe briefly and chose one answer below that best reflects child's interaction with other adults and peers).

Interaction With Others (Please Select One):

Does Not Interact or Indiscriminately Interacts 
Has Hard Time Interacting
Interacts Pretty Well
Interacts Very Well  

7. Child's Current: Weight;      Height

8. Child’s eating habits.  Please note his/her food preferences and briefly describe any eating problems.

Eating Problems
No Eating Problems

9. Child's sleeping habits (if any problems please describe briefly).

Sleeping Problems
No Sleeping Problems

10. Any concerns or problem behaviors observed (if any please describe briefly). In addition, mark all that apply below; if not listed mark 'other.' 

Please mark all that apply; if not listed mark 'other.'

Hyperactive      
Aggressive to others/animals 
lying
smoking
Other 

11. How were problem behaviors addressed?

12. Any health problems?

13. How were health problems addressed?

14. What does the child like (activities, interaction, routines)?

15. What does the child dislike or what frightens him/her?

16. What is your favorite experience about the child so far?

17. Is there any assistance you would like/need to get from the program?

18. Are there any concerns about this child you would like to discuss?

Kidsave Representative should call
Social Worker should call

Best Time of Day to Reach You?

A Reminder: Next week we need you to send us photos.

(Click submit to send.)