Host Family Application Form

HOST FAMILY APPLICATION FORM

The information given on this form is confidential and only used for our records and is subject to the Data Protection Act 1984. However, if you are receiving benefits of any sort we are obliged to disclose to any authority, if requested, any payments made to host families.

PLEASE COMPLETE ALL SECTIONS AND RETURN TO SOUTHBOURNE SCHOOL OF ENGLISH, 30 BEAUFORT ROAD, SOUTHBOURNE, BOURNEMOUTH, BH6 5AL

Surname ______Forename______Title______

Address ______

Post code______Landline______Mobile ______

Email ______

Partner Mobile/Other contact in the home ______

Names of all people living in the house
(Including yourself) / Relationship
(E.g. Mother, Father…) / Occupation / Date of Birth

Host Nationality ______

Work hours/days ______

Has anyone in the house ever worked in the armed forces? YES NO Who? ______

Does anyone in the family smoke? YES NO 

Type of accommodation

BungalowFlatGround floor flatHouse Garden Maisonette 

Preferences – whichstudents would you prefer? (Tick all that apply)

All year roundAll nationalities  If no, please specify______Males  Females 

Age: 9 10 11 12 13 14 15 16 17 18+

(If you want to host under 18s by signing this form you are agreeing to completing an enhanced DBS check)

Can you cater for..? (Tick all that apply)

Vegetarian dietLactose/Dairy free HalalGluten free/Coeliac

What is your family’s religion ______

Pets (type/breed)______

Room available for students (Please write number of rooms in the box):

Single Twin Double Triple En-suite 

How many students could you accommodate at any one time (The maximum is 4):

1 2 3 4 Married couples (x 2 people in double room) 

Family doctors surgery ______

Holidays or dates unavailable ______

Are you registered with other schools?______

If yes, please specify ______

(If you host with any other school by signing this form you agree to not accept student bookings of the same nationality during the same time period)

Family’s interests/hobbies (this gives students a taster of the family they will be staying with so any information you give is helpful in making them feel welcome)

______

Signed ______Date______

HOST FAMILY BANK DETAILS

Account holder’s name______

(as it appears on account)

Account number ______

Bank Name ______

Sort Code ______

Bank Branch ______

Account holder’s address (if different from above) ______

This information is required by Southbourne School of English to enable us to make accommodation payments directly to the host family’s bank.

DBS CHECK

All adult members of your household should read and complete this form.

To comply with the Children’s Act 1989, we are obliged, in certain circumstances, to notify the Social Services Department that you wish to provide accommodation for our students.

We would like to inform you that the following people are NOT allowed to accommodate children:

aanyone who has had a child removed from their care by order of a court

banyone who has been convicted of an offence against a child

canyone who has had an order made against him/her refusing or cancelling registration under the Nurseries and Child minders’ Act 1948 or the Children’s Act 1989.

You will appreciate that the Act provides a necessary element of protection for some students who are potentially at their most vulnerable, away from their own families and possibly with only a limited ability to communicate in English. The Social Services Department has confirmed that any such information passed to them will be treated in the strictest confidence and will only be used for the above purpose.

All adults (aged 16+) living at the address below are required to sign the table below

Would you object to having a DBS check undertaken (if required): Yes  No 

If you already have a valid CRB/DBS check please send a scan/copy of it along with this form. The main carer of the household, if hosting students under the age of 18 years, will be required to provide a valid DBS/CRB check.

Please confirm if you have any Military convictions: Yes  No 

If yes, please give details______

Please confirm if you have ever been subject to a MARAC (Multi Agency Risk Assessment Form):

Yes  No 

If yes, please give details______

I (We), the occupier(s) of the address below have read the above information and confirm that there is no legal reason why we should not provide accommodation for overseas students of any age, and that we have no objection to verification of this being obtained from the Social Services Department.

Host family address______

Name (Block Capitals) / Signature / Date

If you are interested in hosting under 18 year olds and do not hold a valid DBS certificate please fill in the form below.

Forename
Middle Name
Surname
Date of Birth
Gender
Mobile
Email
National Insurance Number
Townof birth
County of Birth
Birth Nationality
Surname at Birth
Surname History with date
Forename History with date
Current Address
At address since (MM/YYYY)
Previous addresses and dates for last 5 years (MM/YYYY)

Please bring your driving licence or passport to the office so we can take a copy. A DBS is £44 to process which is payable by cash, cheque, online transfer or card at the school.

REFERENCE

Please ask someone who is well known to you (excluding family members) to complete the following:

Referee’s name ______

Address ______

______

Tel no. ______

Date ______

Dear Southbourne School,

Re.______

(Name and address of prospective host family)

I am writing to confirm that I have personally known the above-named person for ______years and to my knowledge, can see no reason as to why this family should not be considered suitable to accommodate a foreign student.

Are you completely satisfied that the applicant is not likely to promote “extremist” views (including, for example, being a vocal opponent of democracy, the rule of law, individual liberty, mutual respect for and tolerance of, different faiths and beliefs)? Yes  No 

Yours faithfully

______

(Referee’s signature)

FIRE RISK ASSESSMENT

Fire hazards:

Flammable materials in the household (bedding, soft furnishings…) / Sources of ignition (candles, ovens, fireplaces, open flames…) / Sources of oxygen (windows, vents…)

People at risk in the house: ______

Actions taken to remove risks (e.g. Fire alarms, smoke detectors, clear exits, windows and doors operable…) ______

Please detail your fire escape route in case of emergency ______

Please tick to confirm you will inform students staying with you about fire procedures

Completed date ______

Assessment accepted by Kat Bussy (Accommodation officer)

______

Complete application counter signed by Southbourne School

______