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First
Name:
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Family
Name: |
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First
Name:
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Family
Name: |
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Address:
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Postal
Code: |
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Phone
Home:
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Phone
Work: |
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Fax:
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Cell/Pgr.::
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E-Mail:
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| List
all family names, year of birth, occupation and relationship of
persons living in your household |
| Mr/Ms.:
Age: Occupation:Relationship: |
| Mr/Ms.:
Age: Occupation:Relationship: |
| Mr/Ms.:
Age: Occupation:Relationship: |
| Mr/Ms.:
Age: Occupation:Relationship: |
| Mr/Ms.:
Age: Occupation:Relationship: |
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Language: |
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What is
your first Language? |
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What
other languages are spoken in your home? |
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Pets: |
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Do you
have Pets: |
Yes:
No: |
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If YES
what are they? |
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Please
state preferrence: |
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Male:
Female:
No Preference: |
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Age 14-16
17-19
20-24
Older |
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Lengh of
Stay: 1-4 weeks
4 weeks
No time limit |
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Availability:
Summer Only:
Winter Only:
Any Time: |
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Facilities
students can use in your
home: |
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Kitchen |
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Laundry
Facilities |
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Phone |
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TV |
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Computer |
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Internet |
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Information to help in selecting the student most likely to suit your family: |
| How many student bedrooms do you
have? |
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| How many bathrooms do you
have? |
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| Do
you have a private student bathroom? |
Yes:
No: |
| If not, how many people share the
bathroom? |
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| Which level of your home are your students room?(i.e.basemenr,1st fl,2nd fl) |
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| Will the student have own
room? |
Yes:
No: |
| Do you allow smoking in your home? |
Yes
No
Outside
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| What time is
breakfast:
what time is
dinner: |
| What is the closest subway station to your
home: |
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| What is the nearest main intersection to
your home |
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| Basic furniture: bed:
closet:
desk: chair:
TV: laundry: |
| Have you ever hosted a foreign student before: |
Yes:
No: |
| Are you presently hosting students? |
Yes:
No: |
| If yes, state their age, nationality, sex, length of
stay: |
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| Would you be willing to submit a criminal record check if
required? |
Yes:
No: |
| Are there any dietary restrictions in your home: |
Yes:
No: |
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Please list hobbies, interests and
families activities below:
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Please list any specific house rules, including curfews traditions
etc
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Are there special features within or near to your home that you think students would find helpful or
attractive? (i.e. pool, community centre)
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Please give a general outline of your family's daily schedule:
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Please list any expectations you have of the
student? (i.e. cleaning, laundry, washing dishes and specifications in the use of appliances)
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Please include any additional details that you feel will help us to find a student who is most ideally suited for your family:
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Reference
Referrals: |
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| Name:
Address:
Phone: |
| Name:
Address:
Phone: |
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Type
Your Full Name Here |
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Enter
Today's Date here: |
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Once you have filled in all applicable details, please submit this form. We cannot guarantee you with a student placement. We will keep your name in our database in the event that a student requires homestay in your area.
THA in no way accepts responsibility or liability for damage, loss, or injury to the student or homes as a result of the actions of either the student or the homestay family.
By submitting the form you also agree that you have read and
understand the Host Family Agreement
and that you agree to the terms outlined therein.
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Note:
For proof of origin of this document your IP address and login
will be recorded |
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