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Host Family Application

Host Family Application Form

Homestay Address

Address *

Suburb *

Postcode *

Applicant Details

Carer 1 Salutation *

Dr
Mr
Mrs
Miss
Ms

First Name *

Last Name *

Preferred Name

Date of Birth *

Home Phone

Mobile Phone *

Email *

Occupation *

Religion *

Cultural Background *

Main Language Spoken *

Other Languages Spoken

Do you have current Work with Children Check (WWCC)?

If yes, expiry date: *

Carer 2 Salutation

Dr
Mr
Mrs
Miss
Ms

First Name

Last Name

Preferred Name

Date of Birth

Home Phone

Mobile Phone

Email

Occupation

Religion

Cultural Background

Main Language Spoken

Other Languages Spoken

Do you have current Work with Children Check (WWCC)?

If yes, expiry date:

Emergency Contact Details

Salutation *

Dr
Mr
Mrs
Miss
Ms

First Name *

Last Name *

Preferred Name *

Home Phone *

Mobile Phone *

Email *

Relationship to Applicant *

People Living in your Home

Number of people living in your home (excluding Carer 1 and Carer 2) *

1

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

2

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

3

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

4

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

5

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

6

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

7

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

8

First Name

Last Name

Relationship to Applicant

Gender

Date of Birth

Occupation

Current WWCC Screening

Yes
No

Notes: *

The Department of Human Services (DHS) Screening Unit provides checks of workers and volunteers to organisations, contributing to creating safe environments for children and other vulnerable people.

Accommodation Details

Property Type *

House
Townhouse
Unit
Owner Occupied
Rental Property

Numbers of bedrooms in house *

Numbers of bedrooms available for students *

Numbers of bathrooms in house *

Number of bathrooms available for students *

Does your family have special dietary preference? *

If yes, please specify:

Do you have Pet? *

If yes, please specify (inside, outside and type)

Does anyone in the house smoke? *

If yes, please specify

Inside
Outside

Family interests, hobbies and activities: *

Additional information:

Hosting Preference

Gender *

Male
Female
No Preference

Age Group *

10 – 14
15 – 18
19 and over

Duration *

1 – 14 days
1 – 3 months
3 months and longer

How many students do you wish to accommodate? *

What kind of accommodation can you offer? *

Single Room
Share Room

Would you accept a student with special dietary restriction? *

If yes, please specify:

Would you accept a student who smoke in your house? *

Yes
No

Any additional you would like to add?

Homestay Experience

Are you currently listed to host International students with any other agencies / education provider? *

If yes, please specify: *

Have you hosted any International students in last 2 years? *

If yes, please provide details.

1. Nationality

Duration

Name of School or Tertiary Institution

Year Level

2. Nationality

Duration

Name of School or Tertiary Institution

Year Level

3. Nationality

Duration

Name of School or Tertiary Institution

Year Level

4. Nationality

Duration

Name of School or Tertiary Institution

Year Level

5. Nationality

Duration

Name of School or Tertiary Institution

Year Level

How did you hear about Happy Homestay Adelaide Homestay Program?

Checkboxes1111

Internet
Friend/Relative
Local School
Current homestay referral (if yes, specify name)

Single Line Text

Referees

Please provide 2 referees for reference check:

1. Full Name *

Contact Number *

Relationship to applicant *

2. Full Name *

Contact Number *

Relationship to applicant *

Declaration

Declaration: *

I/We confirm that the information given in this form is true, complete and accurate.
I/We understand the responsibilities and requirements of hosting an international student.
I/We understand that in order to host an International Student:
*** A satisfactory DHS Screening working with children check is required for all persons over the age of 18 residing in the home.
I/We understand that Happy Homestay Adelaide attempts to select genuine students and cannot be held responsible for any undesirable or negligent actions of the student.
I/we approve Happy Homestay Adelaide to collect, hold & work with my personal information/records solely for the purpose of conducting homestay agency duties.

South Australia’s very own Homestay experts professionally matching the needs of international students with Adelaide families since 2003

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Contact

We’d love to hear from you

hha@happyhomestay.com.au

hha@happyhomestay
.com.au

+61 8 8276 4476

Po BOX 495, Park Holme,
South Australia 5043

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