FORM A. Host Family Composition
Family Name:
Address
Suburb
Postcode
Home / Family Email Address
Parent / Guardian Details:
Mother
Father
Title
Home Phone
Step-mother
Step-father
First Name
Date of Birth
Mobile phone
Email address
Occupation
Employer
Title
Other:
Surname
Country of Birth
Parent / Guardian Details:
Mother
Father
State
Step-mother
Step-father
First Name
Other:
Surname
Country of Birth
Date of Birth
Mobile phone
Email address
Occupation
Employer
Host Student Details
First Name
Date of Birth
Surname
Age (as of 1/7/2017)
Mobile phone
Email address
Other Family Members
Name
Relationship
Date of Birth (dd/mm/yyyy)
Occupation
Placement Information
1.
Our family would like to host:
a male
2.
Will the student share a bedroom?
3.
What is your religious affiliation or preference, if any?
4.
How often do you participate in religious services or activities?
Weekly
Monthly
Occasionally
Never
Yes
a female
No
either a male or female
If yes, with whom?
5.
Please comment on hosting someone with a different or no religious affiliation.
6.
Would your family be willing to host a vegetarian or someone with dietary restrictions?
Yes
Prefer not
Strongly object
7.
Does your family have dietary restrictions, including for medical, religious or self-imposed reasons?
Yes
No
If yes, please explain:
8.
Does anyone in your family smoke?
Yes
No
If yes, does anyone smoke inside the house?
Yes
No
9.
10.
What are your feelings about hosting a student who smokes?
No problem
Prefer not
Ok, if he/she smokes outdoors
Strongly object
Do you have any pets?
Yes – indoors
Yes – outdoors
Yes – indoors & outdoors
If yes, please list the type of pets and the amount of time spent indoors.
No
11.
Which language/s is/are spoken in the family home?
12.
What other languages are known by family members?
13.
Do you have / play any musical instruments?
If yes, give details.
14.
No
Has your family hosted before?
Yes
If yes, please give details of when and from which country/ies.
15.
Will any member of the family be away during the student’s stay?
If yes, please give details of who, time away and reason.
16.
WAATI selects candidates according to merit, attitude, flexibility and maturity and does not take into account
colour, race and creed. Please indicate if there are ANY limitations to take into consideration when placing a
student in your family and explain why. If there are no limitations, please type N/A.
17.
Yes
No
Yes
No
The host student anticipates participating in the WAATI 8 week Sending Programme to Italy in:
November 2017
November 2018
No, does not want to participate
FORM B. School and Community Information
School Details
Name of School
School Address
Phone
Fax
School Website
Age range of students
Distance from
home to school
Transportation
method/s to school
Type of school (tick all relevant boxes)
Government
Non government
Boys only
Non-denominational
Independent
Co-educational
Catholic
Anglican
The school uniform is:
Compulsory
Recommended
Will the uniform be loaned to the student?
Yes
No
Girls only
Other:
Specific / special clothing items needed for school to be provided by the Italian student:
e.g black lace-up shoes
Name and year in school of any children in the family who will be attending the same school as the student:
Contact Teacher 1 Details
Name
Work Phone
Work Email Address
Mobile Phone
Home Email Address * mandatory
Contact Teacher 2 Details
Name
Work Phone
Work Email Address
Mobile Phone
Home Email Address * mandatory
Community Information
Type of community:
Urban
Name of closest city centre:
Suburban
Small town
Rural
Other:
Distance to city centre:
Describe the local recreational and cultural facilities available (pool, theatre, sporting grounds etc.)
Describe your community, including social and economic characteristics, ethnic makeup, availability of public
transportation etc. List any websites the participant could visit to learn more about your community.
Describe the climate of the area in which you live during July and August.
FORM C. Host Family Interests and Description
Host Family Profile
1.
2.
List the major interests, hobbies and activities of members of your family.
Describe each member in the family, including the host student. Mention personality, interests, social activities and any
other useful information
3.
Describe a typical weekday in your family. Include common family activities, especially after school routines
and part-time jobs. e.g. Parents wake at 6:00am, children get up at 7:00am. Everyone has breakfast and then dad goes to work at
7:45. Children go to school at 8:00am by bus….
4.
Describe what generally happens on weekends. Remember to include part-time jobs, sporting commitments etc.
5.
Describe what is important in your family. What are your family values?
6.
What kind of chores do you expect the student to help with around the house? e.g. making own bed, washing dishes
7.
What rules do you have in your household? (such as limits on computer, TV or telephone use, etc)
8.
How often and when are your own children allowed to go out in the evening? Under what conditions? What is
their curfew? Be very specific.
9.
Why is your family interested in hosting an exchange student?
10.
The exchange student may come from a family and culture with different habits and expectations about
meals. Are there meals that the student would be expected to get for him/herself? If the student will take lunch
to school, who will prepare the lunch? Do you eat meals together as a family? What responsibilities will the
student and host siblings have in meal preparation and clean-up?
Home Environment
11.
Please give a brief physical description of your home and the exchange student’s bedroom. Also indicate
whether the student will have easy access to computers, musical instruments and a quiet place for study.
12.
If a host parent is divorced or separated and shares custody of the host siblings, please indicate how often the
host sibling/s will be in their other parent’s household. Also comment on whether the exchange student will be
expected to and/or welcome to spend time in the other parent’s household. If not applicable, please type N/A
13.
If anyone in the home has a serious illness or chronic medical condition, please give a brief description.
If not applicable, please type N/A
14.
If there have been any other recent significant changes in your family circumstances, please describe.
If not applicable, please type N/A
This form has been completed by:
Signature:_______________________________
Date: _______________________
FORM D. Signatures
Host Family Commitment
In signing this section the host parent/s acknowledge that if a mutually satisfactory relationship cannot be established with
the first placement, and due discussion / mediation and all other action avenues have been pursued to establish
suitability, then the host student is relocated to a reserve family which may or may not be in the same school as first
enrolled.
Yes, I understand the above statement and have discussed the possibility of relocation with Contact Teacher 1.
Signature of
Father
Stepfather
Guardian
Date
Signature of
Mother
Stepmother
Guardian
Date
Host Sibling Signature
Signature of
Host Brother
Host Sister
Date
School Endorsement
We, the undersigned, consider the
family to be suitable as hosts for an Exchange Student
from Italy. This suitability has been ascertained through the recommended processes from the guidelines established
by the WAATI (Inc) / AFS Intercultura Exchange Program.
Title, Name and Surname of Contact Teacher 1
Contact Phone / mobile
Signature of Contact Teacher 1
Date
Title, Name and Surname of Principal
Signature of Principal
Date
Checked by Exchange Coordinator
Fulvia Valvasori