Host Family Questionnaire - 2008 Final Week

To be completed by the end of Week 6. Please complete a separate form for each child that you are hosting.

Family Name:

City, State:

Your E-mail:

Summer Miracle Child First Name:

Summer Miracle Child Last Name:

Child's Current: Weight;      Height

1. Now that you know the child better, please describe his/her personality.

2. How, if at all, has the child's visit affected your family?

3. How, in your opinion, has the visit affected the child?

About the Child

4. Child's overall emotional state at the end of the program not counting day of departure (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 at the end of the program not counting day of departure (please describe briefly and chose one answer below that best reflects your host 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 at the end of the program not counting day of departure (please describe briefly and chose one answer below that best reflects your host child's interaction with adults)

Interaction With Others (Please Select One):
Does Not Interact or Indiscriminately Interacts 
Has Hard Time Interacting
Interacts Pretty Well
Interacts Very Well  

7. Please estimate child's overall adjustment.
Poor
Fair
Satisfactory
Good
Excellent

8. What is your favorite memory about the child?

9. What kind of family do you think will be suitable for the child?

10. How satisfied are you in your experience with this child?

5 - Very Satisfied
4
3
2
1 - Not At All Satisfied

Please comment on what made you think this way?

11. How satisfied are you with the Kidsave  Summer Miracles Program?

5 - Very Satisfied
4
3
2
1 - Not At All Satisfied

Please comment on what made you think this way?

12. What would you recommend to the future host parent?

13. What would you recommend to the program?

14. Any other comments?

Please send us any additional photos of you and your child that we might use. Send to Kidsave, 5165 MacArthur Blvd., NW, Washington, DC 20016.

Thank you for your help completing these questionnaires. Your generosity in sharing information, your home and your heart is much appreciated.

(Click submit to send.)