USNA-Net Safe Harbor Program Host Application

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To apply to serve as a Host Family, fill out the form below...

Name:	Please include both spouse's first names, if appropriate.
Email:
Re-enter Email:	Include Domain - Example: youremail@YourDomain.com
Street Address:
City:
State:	Outside the US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming     Zip:     Country:

If you do NOT live in a major Metropolitan Area, please complete the following statement...
My home is located miles to the Select Direction ---------------- North Northeast East Southeast South Southwest West Northwest of (Major City or Airport) .

Your Home Phone:	(xxx) xxx-xxxx
Your Work Phone:	(xxx) xxx-xxxx
Your Cell Phone:	(xxx) xxx-xxxx

Your Mid's Full Name:	Grad Year:   2004, 2007, etc.
Relationship to Your Mid or USNA:	Parent Grandparent Other Relative (Explain) Sponsor BGO USNA Graduate Other (Explain)     Explain:

Comments:   Tell us anything else we might need to know in order to process your application or reach you in the event of an emergency...  Pager numbers, alternative phone numbers, what areas, cities or Major Interstate Highways you live close to, etc.