Family Name
First Names (s)
Address - Street
Address - City / Post Code
Address – Country
Date of Birth / Age
Place of Birth / Citizenship
Telephone / Fax
Mobile
Email
Height / Weight
Eye Colour / Hair Colour
Religion/Faith
Passport No. / Expiry Date
Country issuing Passport
FATHER
Family Name / First Name(s)
Address - Street
Address - City / Post Code
Address – Country
Telephone / Fax
Mobile
Email
Business Name
Business Address
MOTHER
Family Name / First Name(s)
Address - Street
Address - City / Post Code
Address – Country
Telephone / Fax
Mobile
Email
NEAREST RELATIVE OR FRIEND TO CONTACT
IF PARENT OR LEGAL GUARDIAN IS NOT AVAILABLE
(2 required)
Name
Relationship / Telephone
Name
Relationship / Telephone
FAMILY STRUCTURE
Name / Age / Relationship / Occupation / Living with family
Yes or No
STUDY INFORMATION
What is your estimate of your level of English?
Beginner / Elementary / Pre-Intermediate / Intermediate / Upper-Intermediate
(Please type in Yes above the level you estimate)
Do you have any specific learning needs or difficulties that could affect your progress?
STUDENT’S INTERESTS
What are your hobbies and interests? / What kind of sports do you take part in?
Can you swim?
How far can you swim? / What kind of sports do you enjoy watching?
Do you play a musical instrument? / Have you had lessons in singing or dancing?
What household tasks do you do in your own home? / Do you have any animals living in your house? If so, what are they?
What kind of food do you like? / What kind of food do you dislike?
Do you have any special dietary requirements? Please note any food allergies you may have. / Do you have relatives living in New Zealand? If so, where?
Which languages do you speak and/or have studied at school?
Language –
Years of study –
Language –
Years of study – / Are you worried about learning a new and different language and culture?
What do you expect to achieve by studying in New Zealand? / What do you plan to do after you have completed your secondary education?
How long do you intend to study at St Hilda’s Collegiate School? / Have your every lived away from home before? Where have you lived and for how long?
Would you like to stay in a home with or without children if your preference is possible or available? / Would you like to stay in a home with or without animals if your preference is possible or available?
STUDENT’S MEDICAL HISTORY
(Confidential under the Privacy Act 1993)
Indicate with an X if you have now, or have had at any time, any of the following illnesses
Illness / Yes / No / Illness / Yes / No / Illness / Yes / NO
Allergies (see below) / Eczema / Painful periods
Anaemia / English Measles / Physical disabilities
Anxiety/Depression / Epilepsy / Rheumatic Fever
Asthma / Gastric disorders / Rubella
Cancer/Tumours / Hepatitis / Scarlet Fever
Chickenpox / HIV, Aids or Aids Related / Tuberculosis
Diabetes / Jaundice / Typhoid
Dyslexia / Migraine headaches / Urological problems
Eating disorders / Mumps / Whooping-Cough
Other
What immunizations have you had? / Immunization / Date / Immunization / Date
Do you take prescription medicines?
Medicine / Taken for / Medicine / Taken for
Do you take herbal remedies?
Herbal remedy / Taken for / Herbal remedy / Taken for
Do you wear glasses or contact lenses?
Indicate with an X if you
Wear / Yes / No / When / Yes / No
Glasses / All the time
Contact lenses / Only in class or study
ALLERGIC REACTIONS AND HEALTH CONDITIONS
Please list below any food, stings, medication etc you have adverse reactions to
Reaction to / Treatment of condition
Are there any health conditions we have to take into consideration when placing you with a host family?

I declare the above information to be complete and accurate

Name of Student
Student Signature / Date
Parent Name
Parent Signature / Date

Reformatted for electronic use 09-Jun-09

Reviewed 19-Aug-10

Rebranded 27-Jun-13