Host Family Application Host Family Application FormPlease enable JavaScript in your browser to complete this form.Homestay AddressAddress *Suburb *Postcode *Applicant DetailsCarer 1 Salutation *DrMrMrsMissMsFirst Name *Last Name *Preferred NameDate of Birth *Home PhoneMobile Phone *Email *Occupation *Religion *Cultural Background *Main Language Spoken *Other Languages SpokenDo you have current Work with Children Check (WWCC)?NoYesIf yes, expiry date: *Carer 2 SalutationDrMrMrsMissMsFirst NameLast NamePreferred NameDate of BirthHome PhoneMobile PhoneEmailOccupationReligionCultural BackgroundMain Language SpokenOther Languages SpokenDo you have current Work with Children Check (WWCC)?NoYesIf yes, expiry date:Emergency Contact DetailsSalutation *DrMrMrsMissMsFirst Name *Last Name *Preferred Name *Home Phone *Mobile Phone *Email *Relationship to Applicant *People Living in your HomeNumber of people living in your home (excluding Carer 1 and Carer 2) *0123456781First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo2First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo3First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo4First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo5First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo6First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo7First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNo8First NameLast NameRelationship to ApplicantGenderDate of BirthOccupationCurrent WWCC ScreeningYesNoNotes: *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 DetailsProperty Type *HouseTownhouse UnitOwner Occupied Rental PropertyNumbers 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? *NoYesIf yes, please specify:Do you have Pet? *NoYesIf yes, please specify (inside, outside and type)Does anyone in the house smoke? *NoYesIf yes, please specifyInsideOutsideFamily interests, hobbies and activities: *Additional information:Hosting PreferenceGender *MaleFemaleNo PreferenceAge Group *10 – 1415 – 1819 and overDuration *1 – 14 days1 – 3 months3 months and longerHow 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? *NoYesIf yes, please specify:Would you accept a student who smoke in your house? *YesNoAny additional you would like to add?Homestay ExperienceAre you currently listed to host International students with any other agencies / education provider? *NoYesIf yes, please specify: *Have you hosted any International students in last 2 years? *NoYes, 1 international student.Yes, 2 international students.Yes, 3 international students.Yes, 4 international students.Yes, 5 international students.If yes, please provide details.1. NationalityDurationName of School or Tertiary InstitutionYear Level 2. NationalityDurationName of School or Tertiary InstitutionYear Level3. NationalityDurationName of School or Tertiary InstitutionYear Level4. NationalityDurationName of School or Tertiary InstitutionYear Level5. NationalityDurationName of School or Tertiary InstitutionYear LevelHow did you hear about Happy Homestay Adelaide Homestay Program?Checkboxes1111Internet Friend/RelativeLocal School Current homestay referral (if yes, specify name)Single Line TextRefereesPlease provide 2 referees for reference check:1. Full Name *Contact Number *Relationship to applicant *2. Full Name *Contact Number *Relationship to applicant *DeclarationDeclaration: *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.Submit