Host Family Form

 

PERSONAL INFORMATION
Parent 1
Full name
Home address
Post code
Home phone
Work phone
Mobile phone
Email address
Occupation / Title
Employer
Work address
Does your job regularly take you out of the home in the evening
Yes
No
Nationality
Main language at home
Religion / Practising
Birthday (DD/MM/YYYY)
Parent 2
Full name
Home address
Post code
Work address
Mobile phone
Email address
Occupation / Title
Employer
Work address
Does your job regularly take you out of the home in the evening
Yes
No
Nationality
Main language at home
Religion / Practising
Birthday (DD/MM/YYYY)
EMERGENCY CONTACT
please detail another person that may be contacted if both parents are unreachable
Name
Address
Telephone Numbers
Relationship to child / children
CHILDREN
First Child
Name
Birthday (DD/MM/YYYY)
Gender
Boy
Girl
School / Nursery hours
Special care
Yes
No
Second Child
Name
Birthday (DD/MM/YYYY)
Gender
Boy
Girl
School / Nursery hours
Special care
Yes
No
Third Child
Name
Birthday (DD/MM/YYYY)
Gender
Boy
Girl
School / Nursery hours
Special care
Yes
No
Fourth Child
Name
Birthday (DD/MM/YYYY)
Gender
Boy
Girl
School / Nursery hours
Special care
Yes
No
Fifth Child
Name
Birthday (DD/MM/YYYY)
Gender
Boy
Girl
School / Nursery hours
Special care
Yes
No
Your form question
Are you currently expecting a baby/babies or planning to adopt a child under the age of two?
Yes
No
If Yes, please give details
Do any of your children have a medical condition your candidate needs to be aware of?
INTERESTS
Please indicate what interests or abilities the members of your family have
Swimming
Horse Riding
Cycling
Skiing
Tennis
Running
Soccer
Gym
Reading
Writing
Arts / Crafts
History
Music
Theatre
Cinema
Movies
Museums
Travelling
Socialising
Trips / Tours
Dance
Parks
Eating out
Photography
Picnics
Volunteering
Cooking
Baking
Fast food
Computers
Other (please specify)
FAMILY AND HOME
Are there any smokers in the household
Yes
No
Any specific dietary restrictions (e.g Vegetarian)
Family religious or cultural practices
Other persons living in the house
Details of any pets
If you have pets do you want them to be cared for
Yes
No
Have you ever had residential help before
Yes
No
Was it a good experience
Yes Completely
Yes quite good
Not great
No
very bad
Other domestic help employed? e.g. cleaner / gardener / housekeeper and their frequency
Please describe your family home (number of bedrooms, bathrooms, garden etc.)
Description of candidates room
Wifi access available
Yes
No
Local amenities / recreational activities
Nearest bus stop
Nearest train / tube station
PERSONAL SPECIFICATION
Preferred Nationality
Preferred Age Range
Level of English
Driver required
Yes
No
Smoker accepted
Yes
No
Gender preference
Male
Female
No preference
Personality type
JOB SPECIFICATION
Start time
Finish time
Total hours per week
Weekly pay
Working days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Babysitting required for
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Level of childcare
Level of housekeeping
Free time
Other perks
Weekly work schedule
Any other details that will help us to select the right candidates for you
AFTERCARE
How did you hear about our agency
Please upload a family photo so that your candidate can familiarise herself with you before the interview
I confirm that I haven’t given any false or misleading information on my application form and I shall notify the agency immediately in writing if there are any changes to the information given above I understand that Wellfield International Placement Agency Ltd cannot be held responsible for any action of applicants engaged through the agency. I have received and agree to the Terms & Conditions of business & the scale of charges within them. It is my understanding that the agency charges an annual renewal fee and if I refer any clients to the agency upon completion of their file I shall receive a £100 credit on my file *
Yes