HOST APPLICATION FORM
Please read the Guidance for Hosts before completing the application form
Personal Details
If you are making a joint application, please fill the personal details of both applicants
1. First Name . . . . Surname ......
Title (eg. Mr/Mrs/Ms/Dr/Rev’d) ......
Date of Birth ......
2. First Name ...... Surname ......
Title (eg. Mr/Mrs/Ms/Dr/Rev’d) ......
Date of Birth ......
Address ......
...... Post Code......
Phone No: Daytime ...... Evening ......
May we call you at work? ......
Mobile: ...... Email: ......
Please tell us why you are interested in hosting:
If you have relevant past experience, including training, please tell us about it (it is not necessary to have experience to be a host, but it will be useful for us to know when dealing with your application).
What is your first language?
Other people living in your house:
Name
/ Date of Birth / Relationship to you (eg. child, parent, lodger)Have you discussed this application with them?
If so, how do they feel about it? ………………….……………………………………………………………………………………..
What accommodation can you offer? egspare room with double/single bed, sofa bed in lounge, use of kitchen/lounge etc
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
REFERENCES: Please give details of two people who will be able to tell us about your suitability for this role. Our preference is that they are not members of your family or household. Please first check that they are willing to provide a reference.
Name
/ Capacity in which known / Address (email address preferred) / Contact Number1.
2.
Your needs as a host: Do you have any specific requirements or anything else you would like to inform us of that will be relevant to your role as a host?eg pets, vegetarians (if so, do you mind if your guest cooks meat?), lots of stairs, health issues
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
……………………………………………………………………………………………………..
Do you have any unspent criminal convictions?
(If the answer is ‘Yes’ please give full details on a separate sheet of paper). This will not necessarily affect your ability to host.
Would you be willing for your contact details to be shared with other hosts?
Signed: ______Date: ______
Please send your completed and signed application form to:
BIRCH
Moseley Exchange
149-153 Alcester Road
Birmingham
B13 8JP
If you need to discuss your application or would like any further details, please contact us on the email above.
And finally………….
Thank you for taking the time to complete this application. We really appreciate your interest in hosting and will contact you soon to arrange to meet and discuss the project
and your application with you further.
BIRCH Network will treat all information that you have provided in this application form as confidential. We will not discuss it with third parties without your consent.