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Helping Family Application

Sur Name :
First Name :
Street Address :
Telephone :
Mobile no :
Email :
Host/Help Mother :
Host/Help Father :
Mothers Occupation :
Fathers Occupation :
Children Names and Ages :
Schools they attend (including day-care/kindies) :
When to pickup children ?
Contact name and telephone number of relative or friends in case of emergency :
Do you have pets? What do you have ?
Does anyone of your family smoke ?	Yes No
Do you want a driver ?	Yes No
Please list duties you expect Student to carry :
For Agency use only :
Help/Student Name :
Nationality :
Age :
Reference # :
How long is the student staying with Family :
School Student will attend :
Times at School From To :
Will you accept a smoker ?	Yes No
When can the student start ?
Flight No :
Date :
Students will leave family/school ?	Yes No
Will your Student have her own bedroom/bathroom :	Yes No
Do you have a computer your Student can use:	Yes No
Please indicate the preferable times of use :
Agree
For the Family :	Yes No
Date :
For the Agency :	Yes No
Ag-Date :