Host family application form by 4F93z6

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									                                    2 Dollis Park, Winston House, Unit 321, London, N3 1HF
                            www.choices-direct.co.uk / email: info@choices-direct.co.uk Tel: 020 8617 8737
                                   Company registered in England and Wales, Reg no: 7441705


                                            Host Family Application Form

FAMILY DETAILS:
Mother’s name:                                                            Father’s name:

Surname:                                                                  Surname:

Email:                                                                    Email:

Tel (H):                                                                  Tel (H):

Tel (W):                                                                  Tel (W):

Tel (M):                                                                  Tel (M):

Address:                                                                  Address:

Town:                                                                     Town:


Postcode:                                                                 Postcode:

Occupation                                                                Occupation

Nationality:                                                              Nationality:

First Language:                                                           First Language:

Religion:                                                                 Religion:

Date of Birth:                                                            Date of Birth:

Does anyone in your household have a criminal record?



CHILDREN
 Name of Child           D.O.B.           Age       Sex      Hours nursery/school        Brief Character Description / Hobbies




Do any of your children have special needs? If so, please give details
YOUR HOME
Is the position residential?
Please describe features of your family home:

Appliances in the home
Washing Machine:
Dryer:
Microwave:
Dish-washer:
Is there other domestic help that you employ? If so, how often?
Do you have any pets?
Do you want the Candidate to look after them?
Are there any other persons living with you? If so, please give their name, age & relation they have with you:

Are there any smokers in the house?
Are there any other aspects of your family life, which should be given special consideration (e.g. vegetarian diet)?



ACOMMODATION OFFERED TO YOUR CANDIDATE
Please describe the bedroom of the Candidate:

Will the Candidate have internet access?
Please describe anything else you will be offering your Candidate:

Name of nearest English course to your home:


YOUR REQUIREMENTS

Start date required?
                                                 Up to 3 months         3- 6 months            6-12 months             Over 12 months
 For how long do you wish to have a
 Candidate for (please tick one or more
 boxes if necessary)



Nationalities preferred:
Approximate age:
Would you accept a male Candidate?
Would you consider a Couple? (the girl usually does the childcare, while the male usually does gardening, driving, handyman jobs):
Would you accept a smoker?
Would you accept a Candidate who occasionally smokes socially and will never smoke in your house or in front of the children?
Do you require a Driver?
Are you looking for someone with any special skills (e.g. swimming, riding, cooking etc)?
Please give name of someone we may contact in case of an emergency:
Name:
Tel:
Working day commencement time:
Finish Time:
Total number of working hours a week:
What wages will you be offering? £
Please give any details of any further information that you feel may assist us in helping you find the right person:
Please describe below the duties of the Candidate in as much details as you can:

 Day         Duties in the morning         Duties in the afternoon            Duties in the evening
 Monday


 Tuesday


 Wednesday


 Thursday


 Friday


 Saturday


 Sunday




Where did you hear about our Agency?


I …………………………………………….declare that the information on this form is accurate and honest
and that I have received read and agree to the Terms & Conditions of your Business.

Signed:………………………………………..............

Date: ………………………………………………….

If at all possible, please provide photographs of your family, house or accommodation when you return this
application form.

								
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