Host Application Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Contact Details Title (Applicant1)* Name Firstname * Surname * Current Address* Post Code* If less than 5 years, please supply full address history for last 5 years* Nationality* ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Date of Birth* Home Telephone* Work Telephone* Mobile Telephone* Email Address* Occupation* Do you have a valid UK driving licence?* ---YesNo Religion* Do you smoke?* ---YesNo If yes, please indicate if you smoke inside your home* Next Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Contact Details Title (Applicant2) Name Firstname Surname Current Address Post Code If less than 5 years, please supply full address history for last 5 years Nationality ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArmeniaArubaAustraliaAustriaAzerbaijanAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia and HerzegovinaBotswanaBouvet Island (Bouvetoya)BrazilBritish Indian Ocean Territory (Chagos Archipelago)British Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCanadaCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKazakhstanKenyaKiribatiKoreaKoreaKuwaitKyrgyz RepublicLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Netherlands)Slovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & S. Sandwich IslandsSpainSri LankaSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Date of Birth Home Telephone Work Telephone Mobile Telephone Email Address Occupation Do you have a valid UK driving licence? ---YesNo Religion Do you smoke? ---YesNo If yes, please indicate if you smoke inside your home BackNext"] Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Other Members of Household Children/Dependents (living at your home address) Name Gender Date of birth General Information Name Gender Date of birth Other household members (i.e. lodger, friend or relative) Name Relationship Gender Regular visitors to your home (i.e. cleaner, relatives) Name Relationship Gender Date of birth Frequency of Visits Do they stay with you overnight? Name Relationship Gender Date of birth Frequency of Visits Do they stay with you overnight? BackNext Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 GENERAL INFORMATION Available bedrooms? Do you have internet? Are parental controls set up on your internet? Do you have previous experience of hosting international students? (if so, please list nationalities) Are you interested in hosting long term and/or short term? Where did you hear about Gateway Education? Do you have valid training for the following? First Aid Safeguarding (please list all the training you have received, i.e. level one, DSL, prevent etc.) BackNext Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 EMPLOYMENT DETAILS Applicant 1 Company Name * Address * post code * telephone * job title * email * Applicant 2 Company Name Address post code telephone job title email BackNext Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 REFERENCES Please give the name and contact details of two suitable referees for each household member over the age of 18. One should be your current employer, if this is not possible, i.e. you are self-employed or retired, please supply details of a contact that knows you in a professional capacity. The second referee should be in a personal context. Family members are not acceptable. Professional Reference: Applicant 1 * Company Name * Address * post code * telephone * Relationship * email * Professional Reference: Applicant 2 Company Name Address post code telephone Relationship email Personal Reference: Applicant 1 * Company Name * Address * post code * telephone * Relationship * email * Personal Reference: Applicant 2 Company Name Address post code telephone Relationship email Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 HOST FAMILY PROFILE The next section is for you to write a 'family profile' that we can send to your student (s) to describe your household. I.e. names/ages etc. of family members, your personalities, occupation, interests, family activities, description of location/accommodation, pets. Please give details of a typical week in your household. Here is an example: We are an active family with a fifteen-year-old son Alex and a 7 years old daughter Emma. I am a teacher and my husband is an engineer. As a family we enjoy taking part in activities, Alex loves to play football and joins training sessions every Wednesday evening and Sunday afternoon and Emma loves to do ballet and attends classes on Tuesday and Thursday evenings. When we have the time, we enjoy camping, walking our dog Bob and going to the cinema. I enjoy cooking and like to try new foods. We are looking forward to welcoming a student into our home and having the opportunity to learn about each other’s culture*. HOST FAMILY DECLARATION Have you or any member of your family had a child removed from their care and been placed in the care of the local authority?* Have you or any member of your family been barred from working with children?* Do you or any member of your family have a conviction? If yes, please give details* Enhanced Criminal Record disclosure checks from the Disclosure and Barring Service (DBS) will be required for successful applicants. This cost will be covered by Gateway Education. Please sign below to confirm that the information given in this form is accurate and truthful and that you understand and agree to a Disclosure check on all household members aged 16 and over, should your application be successful Signed (Applicant 1)*: Date*: Signed (Applicant 2)*: Date*:
