Exchange Student Check-In Student: _________________________________ Country: __________________ 1. Relationship with Host Parent(s). □ Excellent □ Good □ Fair □ Poor □ Very Poor Comments: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. Relationship with Host Sibling(s). (SKIP THIS QUESTION IF YOU DO NOT HAVE HOST SIBLINGS)

□ Excellent □ Good □ Fair □ Poor □ Very Poor

Comments: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 3. Following family rules & adjusting to lifestyle. □ Excellent □ Good □ Fair □ Poor □ Very Poor Comments: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 4. How are you doing in school? □ Excellent □ Good □ Fair □ Poor □ Very Poor Comments: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 5. How are you feeling emotionally? □ Excellent □ Good □ Fair □ Poor □ Very Poor Comments: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 6. How are you doing at making friends, joining groups & participating in the community?

□ Excellent □ Good □ Fair □ Poor □ Very Poor

List any groups, sports, or clubs you have joined:___________________________________________________________ 7. How often do you communicate with friends & family back home? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 8. Please share any successes you have had recently. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 9. When was the last time your liaison contacted you? ______________________________________________________ 10. Would you like your liaison to contact you about any of the issues above?

□ Yes

□ No

11. On the back of this form, write all of your classes & the grades you think you are getting in them.

□ Done