This Form Should Be Used For

♣

This form should be used for:

• Prospective caregivers
• Designated caregivers

Please complete this form and return it to the address below or to the school office:

Applicant/s name/s:
Residential address:
Postal address (if different from above):
Work telephone: Home telephone:
Email: Mobile:
Emergency contact:
Work telephone:
Home telephone:
Mobile:
Household members including other international students:
Name / M/F / Age / Relationship / Occupation / Hobbies

-2-

Medical Information:
Does any member of the family have an existing medical condition that an international student should be made aware of? (E.g. asthma, epilepsy, etc – please circle)
Yes /No
If Yes, please state which family member and the medical condition:
International students will usually be taken to the caregiver’s general practitioner in the event of illness. Please give your family doctor details:
Name:
Address:
Telephone:
International Student Preferences:
Number of students you would like to have: / Preferred gender:
Male / Female
Any other requests or comments:
HouseholdInformation:
Religious affiliation: / Attend church or other place of worship weekly?
Yes / No
Do you follow any special dietary regime? (eg. vegetarian, gluten free)
What languages are spoken in the home by household members?
Do any household members smoke? Yes / No
Do you have any household pets?: Yes / No
If yes, please state:
International Student Arrangements:
Mode of transportto and from school(Please circle):
Walk / Car / Bus / School bus / Other (please state):
Will they be accompanied to school?Yes / No
By whom?
Will student require before and after school care?: Yes / No
If yes, please provide details:

-3-

Police Vet Requirement

Under the “Code of Practice for the Pastoral Care of International Students”, Westminster Christian School is required to request a police vet for all persons aged 18 and over in the accommodation. Please have all family members and other persons living on the property aged 18 and over sign the following declaration:

Police Vetting Declaration:

I hereby give permission for WestminsterChristianSchoolto request a Police Vet:

Name:______

Signed: ______

Date: _____/_____/______

I hereby give permission for Westminster Christian School to request a Police vet:

Name:______

Signed: ______

Date: _____/_____/______

I hereby give permission for Westminster Christian School to request a Police vet:

Name:______

Signed: ______

Date: _____/_____/______

I hereby give permission for Westminster Christian School to request a Police Vet:

Name:______

Signed: ______

Date: _____/_____/______

Theinformationhere given, is, to the best of my/our knowledge, true and correct.

Signature of Applicant/s:______

______

Date: ______/______/______

WESTMINSTERCHRISTIANSCHOOL, 31 WESTMINSTERGARDENS, UNSWORTH DRIVE, ALBANY 0632

TEL / FAX: 09-444-1983

Email: bsite: