Homestay Family Registration Form - 2006

HOMESTAY FAMILY REGISTRATION FORM - 2010

DATE:______(Please print clearly and complete fully)

SURNAME: ______GIVEN NAME/S:______

ADDRESS:______

HOME PHONE:______

WORK PHONE (Mother):______NATIONALITY: ______

WORK PHONE (Father):______NATIONALITY: ______

EMAIL: MOBILE#:______

1. Is English the first language spoken in your home? ☐Yes ☐No Are there any other languagesspoken in your home? ______

2. How many bedrooms are there in your home? ______bathroom(s)_____

toilet(s)_____ lounge/family rooms_____

3. Pets in your home: Cat, Dog, Guinea pig, Mice, other? ______? Name .

Are your pets kept ☐inside only☐outside only☐both inside & outside (please check)

4. Student preferences: Male / Female / Both / 15yrs+ / 20yrs+ / 30yrs+ / No age preference

5. *The working with children suitability check or Blue Card is a requirement of the state of Queensland andmust be held by all residents of the home-stay over the age of 18 years of age for homes accepting students under the age of 18 years.Please include the details of family members holding a Blue card :

Father:☐Yes☐No. Name on card: ______Card No: ______Expiry date:______

Mother:☐Yes☐No. Name on card: ______Card No:______Expiry date: ______

Others 18yrs+;

☐Yes ☐No. Name on card: ______Card No: ______Expiry date: ______

☐Yes ☐No. Name on card: ______Card No: ______Expiry date: ______

If a Blue Card is not held, please provide date application was made;

Father: / / Mother: / / Other: / / .

6. TRANSPORT: Please indicate the most convenient transportation to the Brisbane City Centre from your home.

7. Do you have a computer your student/s can use? ☐Yes ☐No

8. Can he/she access the internet? ☐Yes☐No

9. What services/facilities are close to your home ☐Parks☐Shops ☐Bus Stop ☐Train Station☐Bank☐Post Office (please check)

10. Would you accept a student that smokes? ☐Yes ☐No

If yes, where will he/she be permitted to smoke?☐inside ☐outside ☐both inside & outside)

11. What tasks around the house do you expect of your student? ______

12. Do you eat a variety of foods? ☐Yes ☐No

13. Should your student have a special dietary requirement, areyou willing to cater for this need? ☐Yes ☐No

14. What do you enjoy doing on the weekends? ______

15. Is it possible for your student/s to join in these activities? ☐Yes ☐No

16. Are there any periods where your student/s would be home alone?☐Yes ☐No

17. If so, please state which days and approximately for how long? ______

18. When is your accommodation available from? ______

19. Payment of the homestay fee is made to you via internet banking. To do this we require your Bank Account details;

A/C Name: ______

Bank: ______

BSB: ______

A/C No: ______

 The above information I have written is true and correct at the time of completing this registration form, andshould any family information/circumstances change, we will inform Earthbeat about it.

 YES, I agree to allow Earthbeat to send the information contained in this registration form to students enrolled with Earthbeat, with the intention of a Home-stay Placement.

 YES, I agree to Earthbeat’ request, that I send the required information to the Approved Screening Agency in orderto obtain a Police Check and the Working with Children Check to obtain a “Blue Card”.

 I do solemnly swear that I, and those persons who permanently reside at my/our address stated above in theregistration form do not have any criminal convictions, partake in any criminal activity or consume unlawfulsubstances which are illegal in Australia.

 Should our family agree to home-stay a student under the age of 18yrs we will be required to:

Provide the general care of the student during the term of his/her stay including:

a) Attend initial interview at High School

b) Liaise with Earthbeat staff on student’s health, any social or school related issues and general updates andfeedbacks etc.

c) Liaise with the high school regarding writing notices of absence, attending school meetings regarding thestudent as deemed necessary by the school.

d) Assist the student in seeking necessary medical attention and obtaining a medical certificate if required.

e) Give notice in advance if the student is to stay elsewhere other than your home or if your family plans to beaway. A student under the age of 18yrs cannot stay at home alone, overnight.

Student Holidays

In the case of long term students, where mid or end of year holidays may be taken, the student may opt to keep their room whilst away. The host family will be paid athalf the usual rate for those weeks the students is absent (usually two or three weeks).

Conditions/Disclaimer

Earthbeat makes all efforts to organise, facilitate and ensure that all arrangements for home stay programme are in place and finalized prior to thearrival of the student. However, Earthbeat denies all responsibility for any injury, damage, loss, accident caused by circumstances outside itscontrol. Earthbeat is not a principal and acts solely as an agent between the principals and third party (Client/students and host families)

We/I, the host mother/host father have read and understood the Home-stay Family Guidelines and theHome-stay Family Registration Form 2009 and understand my/our responsibilities and obligations,while being registered as a host familyEarthbeat.

Host Mother: ______Signature:______

Date: ______

Host Father: ______Signature:______

Date: ______

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Earthbeat HOMESTAY FAMILY REGISTRATION FORM