Title/Forename:

Your Surname

Home Address

Home Telephone Number:

Mobile number:

Work telephone:

Email address:

Native language:

.....

Host 1

D.O.B:

Occupation Employment History:

DBS Held:
NoYes

Year DBS taken:

.....

Host 2

D.O.B:

Occupation Employment History:

DBS Held:
NoYes

Year DBS taken:

.....

Children living away from home:
YesNo

.....

Children living at this address 1:

D.O.B:

Occupation:

.....

Children living at this address 2:

D.O.B:

Occupation:

.....

Other Adults living at this address:

D.O.B:

Occupation:

DBS Held:
NoYes

Year DBS taken:

.....

Other Adults living at this address 2:

D.O.B:

Occupation:

DBS Held:
NoYes

Year DBS taken:

.....

Do you have any pets?:
NoYes

Do you have Wi-Fi:
NoYes

Does anyone in the household smoke:
NoYes
......
Location
How far is your house from the town centre?:

How long would it take to walk from your house to the town centre?:

Is there a frequent bus service: NoYes

Is there a bus stop near your house: NoYes

How far is the bus stop?:

.....

Accommodating students:

Please tick which of the following types of students you would be happy to accommodate:

MalesFemalesShort term (1-4 weeks)Long term (1-12 months)Students over ChristmasSmokers

Please tick which ages you would prefer:

Under 1616-1818-3030-50Over 50

Can you cater for?

VegetariansMuslim DietSelf-CateringGluten free/Coeliac

Please number how many rooms are available?

Single bedroom


Twin bedroom


Double bedroom


En-site bedroom

Have you had students before?:
NoYes

Further Information:

Please provide information on your hobbies and interests:

EXTRA DOCUMENTS: Driving license/insurance document/passport. Gas Safe certificate for your boiler and/or gas fire.

......

References
Please give the names and addresses of two people who can provide a reference for you. They can be a host family, a
friend, a work colleague, etc. You cannot use family members.

......

Reference 1
Name:

Profession:

Relationship:

Address:

Postcode:

Telephone:

E-Mail:

......

Reference 2
Name:

Profession:

Relationship:

Address:

Postcode:

Telephone:

E-Mail: