- 5 -
Samantha Daniels Consulting INC
HOST FAMILY APPLICATION
Please indicate your interest:
For Short Term Summer ______
For Short Term Winter ______
For Long Term Program ______
Have you applied to any other Agency? Yes No
Date: Referred by
Host Mother’s Name:
Host Mother’s Occupation: Employer:
Work # Days/Hours of work:
Host Father’s Name:
Host Father’s Occupation: Employer:
Work # Days/Hours of work:
Home Address:
City: Postal Code:
Home Phone No. (Cell # for
Do you use text messaging on your cell? Yes No
YOUR EMAIL address:
(this is important as we communicate with our host families via email)
Do you speak another language other than English? If so, what language?
List all the people who live in your home now, including any students as well as your children: If your children are grown and have moved out, please list them so that we know you have raised children but indicate that they have moved out.
Name Date of Birth Relationship Name of School or /Occupation
.
Have you every hosted a foreign student in your home? Yes ______No______
Nationality Sex/Age From Which School/Agency When Length of Stay
Hobbies in the Family (leisure activities, sports, musical instruments) – This assists in placing students with similar interests).
(Some of our students request a “Christian” family and wish to attend church with the family)
Do you attend a Church? Yes No If yes, which church/religion______
(Some of our students wish to play a musical instrument in your home)
Does anyone in your family play a musical instrument? Yes No
If yes, which instrument?
Do you have a piano in your home? Yes No
Smoking
Does anyone in your family smoke? Inside the Home Outside the home
May a student smoke in your home? Outside is acceptable
What your home offers in ACCOMMODATION:
How many bedrooms do you have available for students? On what floor _____
Please indicate what level in your home the student accommodation is on. This is important as many students do not like basements. The bedroom needs to have a good size window with lots of light and a good source of heat.
What kind of beds are in the bedroom(s) Single Double Queen Bunkbed
Do you have a private bathroom for the student? Yes No
Do you have the internet in the student’s bedroom? Yes No
House ____Townhouse _____Apartment_____ # of Levels # of Bedrooms _____
# of Kitchens # of Bathrooms _____ Study Areas ______Other
Please list the time of day you leave for work and the time of day you arrive home from work:
Also please list the evening schedules for activities for your family.
MOM MOM DAD DAD Evening Activities
Departs Arrives Departs Arrives (Sports or recreation)
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
What time each day do you sit down for a family dinner:
Please complete the following. This is important. You need to familiarize yourself with public transportation in your area: You can research this at www.translink.bc.ca or on Google Maps.
Nearest Public Bus Number & Name:
Nearest School(s):
Approx. travel time:
Short Term Students and some long-term students require drop off and pick up. Please confirm whether you are willing and able to transport students to and from school? (Sometimes car pools can be set up between host families.)
Please ensure you answer this question. Yes No
Please answer the following regarding your home environment.
Do you have any Pet(s). If so, please specify type of pet, inside or outside and provide their names:
Type of Food/Diet in your home:
Important House Rules:
Please indicate gender preference of student: Female Male: Either:_____
Please provide 2 reference letters
Prior to becoming a host family, you will be required to provide a Criminal Record Check, at your own cost, for all adults residing in your home.
You also need to provide a copy of the front page of your house insurance showing $1 Million liability coverage. Please attach to this application form.
Please tell us why your family is interested in hosting a student.
PLEASE READ THE FOLLOWING CAREFULLY:
I/We understand that:
· Samantha Daniels Consulting INC. prepared a Host Family Profile based on our completed application form. I/We agree to contact the homestay coordinator should our family situation change.
· we are expected to provide a welcoming and secure environment;
· discovery of any problems in the home, such as sexual harassment, drug problems or alcohol abuse, the student will be moved.
· an applicant family must meet the requirements or criteria of the homestay program as set out in the Homestay Family Policies and Guidelines and that the Homestay Coordinator reserves the right to terminate the family’s participation in the program.
· completion of a Criminal Record Search by all adults living in my home is mandatory.
· I/we must maintain house insurance with a minimum of $1 Million liability coverage. Samantha Daniels Consulting recommends that we advise our insurance agent that we are hosting international students to prevent your insurer from denying coverage.
· Samantha Daniels Consulting INC. will make every effort to make the most appropriate student placements. In the event an assigned student causes damage to my home or property, I agree to assume all liability for loss or damage and I release Samantha Daniels Consulting INC. and its employees from all liability arising out of my participation in the program. Supervision of all students is important.
· Host families pay a placement fee for student(s) placed in their home as payment for continued support to the family during the applicable time period. (see Homestay Family Policies and Guidelines). We do confirm, in advance, the remuneration you will receive in your hand.
· I agree to advise Samantha Daniels Consulting INC. IMMEDIATELY should there be any additional students/people move into my home. This is important because Samantha Daniels Consulting provides all clients with a host family profile which must be accurate.
· I also agree not to deal directly with the agents that Samantha Daniels Consulting INC. introduces to me.
· I also agree NOT TO REQUEST ADDITIONAL MONIES FROM ANY STUDENT OR ADULT PLACED IN MY HOME. If I believe additional monies are required to be paid, I will contact the Homestay Coordinator Samantha Daniels Consulting INC. to discuss.
· I understand the “CONFIDENTIALITY” clause set out in the Homestay Family Policies and Guidelines which states, in part, that there will be no discussion regarding financial aspects or Homestay fee payments with students who are placed in our home. I will contact the Homestay Coordinator should the students make enquiries.
I am in agreement with the policies and conditions of the Homestay Policies and Guidelines for Homestay Families.
(Signature of Host Parent) Date
(Signature of Host Parent) Date
Please email us RECENT digital photos of your family, the student’s bedroom(s) showing window, desk and sleeping areas including the bathroom they would be using and the exterior of your home.
Please forward this ORIGINAL completed and signed application with the following:
1. the Signed Agreement form from the Guidelines (policies and guidelines)
2. copy of your insurance coverage indicating $1,000,000 liability (first page of the Policy shows your coverage)
3. two reference letters (from colleagues and/or neighbours who have known you for a minimum of 3 years and can attest to your character). The letters should have the writer’s address and contact number(s) they can be emailed; and
4. a criminal record check for all adults living in your home. If you have a separate suite that you rent out and your tenants will not be part of your household, then they do not require a criminal record check – (Attend at your local police station to pay for and request they provide the criminal record check to you or to our Company. We do require the original Criminal Record Check, NOT a photocopy.
To Attn: Samantha Daniels Consulting INC.
307-1148 Heffley Crescent, Coquitlam, BC, V3B8A6
OUR COMPANY PROCEDURE:
We will contact your family when we have prospective students requiring homestay in your area or when we have a group coming in the summer or winter months. We will arrange for a convenient appointment where we will wish to meet all family members and view your accommodation.
Please note that we do require photos of your family, including any pets, the exterior of your home, the student(s) bedroom area, showing the window, desk and bed and student’s bathroom area. Remember you are marketing your home with these photos so please ensure the photos show your home in its best light.
Should you have any questions, further comments or changes to your application please email us at .
Please email Homestay Family Photograph(s) including your FAMILY, any pets, your student accommodation SHOWING THE WINDOW including the student’s bathroom and the exterior of your home to
We do require digital photos to be kept on our computer so that we can keep these in your family folder and share them with prospective students OR their agents for their family to market your family and your home. Photos help students and their parents in their decision to choose your family and having photos of their host family helps to lessen any anxiety they may have about coming to Canada.