Homestay Application Form - South Australian Government Schools

1. Nominated Homestay

Are you applying to host a specific student?*

Yes

Nominated Student Name:

First Last

Nominated Student Birthdate:

Are you interested in hosting other students through South Australian Government Schools?*

Yes

2. People living in your home - Resident 1

Please provide the following details about yourself.

Name*

First Middle Last

Date of birth*

Gender*

Email*

Mobile Number*

Home Number

Address (Street No. & Name)*

Suburb*

Must be in South Australia

Postcode*

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

How many other people reside in the home?*

If other, how many?

Resident 2

Name*

First Middle Last

Date of birth*

Gender*

Mobile Number

Only required if over 18 y/o

Relationship to applicant?*

If other, please specify

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

Resident 3

Name*

First Middle Last

Date of birth*

Gender*

Relationship to applicant?*

If other, please specify

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

Resident 4

Name*

First Middle Last

Date of birth*

Gender*

Relationship to applicant?*

If other, please specify

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

Resident 5

Name*

First Middle Last

Date of birth*

Gender*

Relationship to applicant?*

If other, please specify

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

Resident 6

Name*

First Middle Last

Date of birth*

Gender*

Relationship to applicant?*

If other, please specify

Please advise occupation or school attending*

Current Working with Children Check?*

Yes

Please provide SRN number

If you do not know the SRN please contact the DHS Screening Unit directly on 1300 321 592

Do any members of your household work night shift?*

Yes

If yes, please specify

Please upload a copy of your WWCC(s) (if available)

Drop files here or

Max. file size: 256 MB.

3. Emergency Contact Details

This person should be someone who doesn't live in the home who can be contacted in an emergency situation.

Name*

First Last

Date of birth*

Relationship to applicant*

If other, please specify

Address*

Suburb*

State*

Post Code*

Phone Number*

Email*

4. Fill-in Homestay Details

Please provide details of someone aged 25 years or older, who could stay in your home and care for the international student(s) in your absence (planned holiday / emergency). We will arrange a Working with Children Check for your fill-in homestay. Please ensure your nominated person is aware you have provided us with their details. If you are unable to identify a fill-in homestay, IES will arrange a temporary placement in case of emergency or planned holiday.

I am able to identify a fill-in homestay*

Yes

if yes, please complete the following details on fill-in homestay:

Full name of fill-in homestay:

First Last

Date of birth of fill-in homestay:

Address of fill-in homestay:

Phone Number

5. Student Preference

Gender*

Male

Female

Any

Duration*

1-6 Months

6+ Months

Any

Nationality*

No Preference

European

Japanese

Vietnamese

Chinese

Brazilian

Other

Is other, please specify

Age Group*

12-15

16+

Any

How many students can you accommodate in single bedrooms?*

Students are required to have their own room under the main roof of the home

Which types of dietary needs are you able to cater for?*

Gluten Free

Vegan

Vegetarian

Halal

Specific Food Allergies

Other

If other, please specify

Would you consider hosting a student with additional needs? (e.g. allergies, asthma, epilepsy?)*

Yes

If yes, please specify

Emergency Accommodation - From time to time our office requires homestays at short notice to accept students for a variety of reasons. The call to take a student in an emergency situation most often happens after hours, and occasionally in the middle of the night. Would you be willing to accept a student in an emergency situation (temporarily or permanently)?*

Yes

6. About your family

What is your family cultural background?*

Does your family have any religious affiliations?*

Yes

If yes, Please provide details

Do you attend regular services?

What is the main language spoken at home?*

Does your family have pets?*

Yes

If yes, please specify what type of animal and if they are indoor or outdoor pets e.g. 1 Dog, inside/outside.

Does anyone in the home smoke?*

Yes

If yes, do they smoke indoors or outdoors?

Please write a brief description of your family*

The information you provide gives the opportunity to introduce your family to future students. This may include activities your family enjoys, information about your lifestyle and what you are looking forward to about hosting international students. 100 words maximum.

7. Prior Homestay Experience

Are you currently listed to host international students with any other organisation(s)?*

Have you hosted international students in the last 2 years?*

Yes

If yes, please provide details

8. Homestay who referred you to the Homestay Program? (if applicable)

Details

First Last

Why did this Homestay recommend the Homestay Program to you?

9. How did you hear about the South Australian Government Schools Homestay Program?

How did you hear about the South Australian Government Schools Homestay program?*

If other, please specify

Why are you interested in becoming a homestay?*

Looking for a rewarding experience

Receiving a weekly allowance

Interested in other cultures

Would like company in the home

Want to expand my family’s horizons

Other

If other, please specify

10. Photos

Please provide photos of your family, home and pets – These photos will be provided to agents and new students as part of your homestay profile. Please ensure rooms are neat and tidy. Please include: • Recent family photo • Photo of your pets • Front of the home • Student bedroom • Student bathroom • Kitchen • Dining • Lounge • Outdoor area/backyard

Files

Drop files here or

Max. file size: 256 MB.

If you are unable to provide photos at this time, our office will contact you and add them to your profile at a later date.

11. Homestay Declaration

IMPORTANT: This is the final step to the application form, please review all parts of the application before submitting. I declare that the information in this application form is complete and correct. I understand that providing false or misleading information or non-disclosure of relevant information may result in the homestay application being assessed as unsuitable or previous successful accreditation being revoked. I have read and understood the Terms and Conditions for Homestay Providers above and accept the responsibilities and duty of care detailed in the document. By clicking Accept Declaration and entering your full name below, you acknowledge and agree to the above Declaration.

Full name*

Date*

Accept Declaration*

Yes

Personal information supplied in this application will be used by the Department for Education only in connection with the homestay application with the South Australian Government Schools program.