Apply To Be a Host Family with ELI Schools Survey

Question Title

* 1. Main Applicant Details (Primary Host Contact)

Full Name

Home Address:

Date of birth:

Mobile Number:

Home phone:

Email:

Occupation:

Interests:

Question Title

* 2. Second Host Contact - (partner, spouse or other adult)

Full Name

Date of birth:

Relationship to host:

Mobile Number:

Occupation:

Interests:

Question Title

* 3. Child 1 (Skip if does not apply)

First Name:

Date of Birth:

Male or Female:

Question Title

* 4. Child 2 (Skip if it does not apply)

First Name:

Date of Birth:

Male or Female:

Question Title

* 5. Child 3 (Skip if does not apply)

First Name:

Date of Birth:

Male or Female:

Question Title

* 6. Child 4 (Skip if does not apply)

First Name:

Date of Birth:

Male or Female:

Question Title

* 7. Other Adults Living in the Home (Family or Otherwise)

Full Name

Relationship to host:

Gender:

Age or Date of birth:

Occupation:

What rooms do you have available in your home?

Question Title

* 8. Bedroom 1 - How many beds in the room?

Single Bed

Twin Beds (2 Singles)

Triple Beds (3 singles)

Double bed

Question Title

* 9. Bedroom 1 - Is it private ensuite bathroom access or shared bathroom?

Private ensuite

Shared bathroom access

Question Title

* 10. Bedroom 2 - How many beds in the room?

Single Bed

Twin Beds (2 Singles)

Triple Beds (3 singles)

Double bed

Question Title

* 11. Bedroom 1 - Is it private ensuite bathroom access or shared bathroom?

Private ensuite

Shared bathroom access

Question Title

* 12. Do you have WIFI Internet in your home the student can use?

Yes

Question Title

* 13. Do you have pets living in your house?

If Yes please give details:

Question Title

* 14. Does anyone in the home smoke inside the house?

Yes

Question Title

* 15. Do you allow students to smoke inside the house?

Yes

Question Title

* 16. Routine: Is there any adult in the home during the day?

Yes

If Not, when does the first person arrive home?

Question Title

* 17. Meals: Please indicate which meals you can provide if requested?

Vegetarian

Vegan

Coeliac

Allergy/Peanut

Question Title

* 18. Access: Is your home suitable for disabled or students with limited ability?

If Yes, please give details

What type of students would you prefer? - we can't guarantee but will give options

Question Title

* 19. What age of students would you prefer?

Groups (age 12-17) - minimum 2 per time

Adults (aged 18+) - mainly placed as individuals

Either (no preference)

Question Title

* 20. What gender would you prefer?

Male Only

Female Only

Either (no preference)

Getting to ELI Schools - the daily commute for students

Question Title

* 21. What is the best form of transport to ELI Schools from your house?

Question Title

* 22. How long does the journey take?

Legal Declaration & Data Protection

Question Title

* 23. I have read and agree to the ELI Schools Host family guidelines

Yes

Question Title

* 24. Have you or any family member been convicted of a criminal offense?

Yes

Question Title

* 25. Have you or any family member had a child removed by order of the courts?

Yes

Question Title

* 26. I understand that Garda Vetting is a requirement and agree to complete the process with ELI Schools

Yes

Question Title

* 27. I understand that Garda Vetting is a requirement and agree to complete the process with ELI Schools

Yes

Question Title

* 28. I authorise ELI Schools to use my personal contact information for the purpose of contacting me regarding hosting international students and to supply this information to students booked to stay in my home:

Yes