Kiwi HomeStay

Family Details - Family Member 1

Family Name:

First Name:

Occupation:

Phone:
Home Business

Fax:
Home Business

Mobile:

Family Details - Family Member 2

Family Name:

First Name:

Occupation:

Phone:
Home Business

Fax:
Home Business

Mobile:

Home Address

Address 1:

Suburb (optional):

City:

Area Code (optional):

General Information

Do you:
Own Rent Other (Specify)

Email Address:

Religion:

Any Specific Dietary Observances:

Does anyone in the family have a serious medical condition (Please specify):

Interests / Hobbies:

Does anyone in the family smoke:
Yes No

Do you have any pets:

What languages are spoken:

Under new legislation in 2002, all homestay families are required to undergo a police vetting check. Do you have any objection to this:
Yes No

Children

Do you have any children:
Yes No

If yes, please complete below...

Name	Date of Birth	Gender
		M F
		M F
		M F

Accommodation Details

How many rooms do you have available:

Will the student have:
Own Bathroom Share Bathroom
Own Toilet Share Toilet
Desk for study No desk for study
Internet access No internet access
Own phone line No phone line
Television No television
Sky TV No Sky TV

Student Preference

Gender:
Male Female Either

Approx age:

Nationality:

Smoker or non-smoker:
Smoker Non Smoker

Comments

Please list any other details which may be relevant to your application:

Referees

Please give the names and telephone numbers of two people who we can contact as referees:
Name Phone
Name Phone

By submitting this form you are agreeing to the conditions for hosting International Students.