Host Family Registration Form

Host Family Registration Form

Contact Information

Name: ______

Address: ______

______Postal Code : ______

Home Telephone No.: ______

Husband

Forenames ______Age ______Nationality ______

Mobile Telephone No.: ______Email Address: ______

Religion ______Academic Qualification______

Occupation: ______(Full-time /Part-time) Work contact no.______

Interest/Hobbies ______Special Skill ______

Do you hold a clean driving license ? Yes/No Have you been DBS checked & can provide reference ? Yes/No

Wife

Forenames ______Age ______Nationality ______

Mobile Telephone No.: ______Email Address: ______

Religion ______Academic Qualification______

Occupation: ______(Full-time /Part-time) work contact no.______

Interest/Hobbies ______Special Skill ______

Do you hold a clean driving license ? Yes/No Have you been DBS checked & can provide reference ? Yes/No

Children(Please fill details of all children & specify whether currently living at home)

Name / Sex / Date of birth / School/College / Interest/Hobbies

Other adults likely to stay at your home

Name ______Age ______Relationship ______

(PLEASE NOTE: All adults regularly staying in your home will be required to undergo Police and Social Services checks in compliance with The Children Act.)

Accommodation (* = delete as appropriate)

We own/rent* our home

Is there a separate bedroom for a host ship child(ren) ? Yes ____ No ____

If yes, please specify the details as below:

Room 1: (double/single) ______Bed (single/double/bunkbed): ______With desk (Y/N) _____

Room 2: (double/single) ______Bed (single/double/bunkbed): ______With desk (Y/N) _____

Room 3: (double/single) ______Bed (single/double/bunkbed): ______With desk (Y/N) _____

If any of the above room is an ensuite room, please specify : ______

Guest Pupils/Students

How many pupils could you host at any one time ? ______

Would you prefer male or female students ? ______

Are you prepared to cater for any special dietary requirements ?______

Transport

Do you own your private car ? Yes ____ No_____ If yes, please specify:

Do you willing to pick up the student at airport and send him/her to school? Yes/No (Provided that £0.5 per mileage is given)

General

Have you acted as host family before ? Yes ___ No ____ If yes, please give brief details:

Year ______Nationality of the child ______

Are there any smokers in your household ? Yes ______No ______

Do you have any pets ? Yes ______No ______If yes, please specify ______

Internet Access ? Yes _____ No ______If yes, is it wireless ? Yes ______No ______

Language spoken ______

Would you be prepared, if asked, to have a Police &/or Social Services check under the provisions of The Children Act ? Yes ______No ______

Signed ______Date ______

References

Please find two referees to endorse your application. If possible obtain one personal and one professional reference. (Please provide only at time of home visit.)

I endorse this application and I would unreservedly recommend this family. I consider they are suitable persons to host children from overseas as guest in their home.

Professional Personal

Name ______Name ______

Address ______Address ______

______

Telephone ______Telephone ______

Occupation ______Occupation ______

How long have you known the family ____ How long have you known the family____

Signed ______Signed ______

Date______Date ______

Please send this completed form to Herman Chiu at the address below, either scanned and emailed or hard copy.

Mission Links UK Educational Consultants

35 Alfreton Road, Selston, Nottingham, NG16 6DL

Email:

Mission Links UK Educational Consultants

35 Alfreton Road, Selston, Nottingham, NG16 6DL

Tel: + 44 (0)1773 583388 Fax: + 44 (0)1773 252088

Email: Website: