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Homestay 2022
Maribel
2022-05-17T08:50:26+00:00
1
PERSONAL DETAILS
2
HOME DETAILS
3
STUDENTS PREFERENCES
4
PAYMENT DETAILS
5
CHILDREN ACT
6
FIRE RISK ASSESSMENT
PERSONAL DETAILS
Name
*
First
Last
Address
*
Postal Code
*
City
*
Country
*
Mobile number
*
Other telephone number
Email
*
Do you check this regularly?
*
Yes
No
Your Date of Birth
MM slash DD slash YYYY
List
*
Name
Surname
Sex
Date of Birth (dd/mm/yyyy)
Male
Female
Add
Remove
Do you have grown children not living at home?
*
Yes
No
Do you hold a "Child workforce in the home" DBS?
*
Yes
No
Applied for by whom
Registered No
Have you had any involvement with Social Services?
*
Yes
No
ABOUT YOUR HOME AND FAMILY
Do you have pets?
Yes
No
Kind of pet
How many?
Add
Remove
How many students can you host at one time?
Number of rooms available for Students
*
For example: 1 single on-suite
1 twin with shared family bathroom
2 singles, shared bathroom only for students use...
Please upload a photo of the accommodation (bedroom)
Max. file size: 256 MB.
Please upload a photo of the bathroom the students will be using
Max. file size: 256 MB.
Please upload photo of the common area, i.e. living room
Max. file size: 256 MB.
Describe you WIFI
Limited
Unlimited
Fast
Average
Slow
Smoking details
*
Outside only
Not in bedroom
Anywhere
Lounge/kitchen only
Does anybody smoke within the family?
*
Yes
No
Do you have a piano that students could use?
*
Yes
No
Tell us about nearby public transport
*
Are you available to pick from school or would you prefer us to arrange taxis?
*
We can pick up from school
Arrange taxis please
Tell us about your family
*
How do you describe your family?
Tell us about your family's interests and hobbies
*
How often do you have dinner together?
*
Every day
3-4 times a week
Weekends only
Never
STUDENT REFERENCES
Hosting who and when.
Preferences
*
Male
Female
No preferences
Do you have any of the following diets in your home?
*
Vegetarian
Vegan
Kosher/Halal
No red meat
No pork
Gluten free
Lactose free
Other
Are you happy to cater for any of the following diets?
*
Vegetarian
Vegan
Kosher/Halal
No red meat
No pork
Celiac - Gluten free
Lactose intolerant
Nut allergy
I prefer not to cater for special diet requirements
What level of involvement do you expect the student to have with your family?
*
1 Independent
2
3
4
5
6
7
8
9
10 Fully engaged in family life
PAYMENT DETAILS
Payment method
By Cheque
By BACS
Please choose the method by which you would like to be paid. (Please note we don't pay to Building Society accounts. Only Banks.)
Name
Mr.
Mrs.
Ms.
Miss
Dr.
Prof.
Rev.
Prefix
First
Last
Sort Code
Account number
REFERENCES
Please provide details of two persons whom we may contact with reference to your suitability to host children.
Referee 1
*
Email
*
Referee 2
*
Email
*
DECLARATION
English UK code of practice
*
I/We agree to abide by the English UK Homestay Code of Practice for providers of homestay accommodation for English Language Students
-To encourage the student to speak English as much as possible in your home
-To encourage the student to feel at home and to treat him/her as a member of the family rather than a paying guest
-Not to host other students of the same native language at the same time unless by special arrangement with the students and the schools
-Not to host students aged over 18 years with students aged under 18 years of age, unless special arrangement with the students and school
-To provide a clean and comfortable student environment in which it is possible for the student to carry on his/her English studies properly when appropriate.
-To provide the student with a balanced and appropriate diet.
-To show due concern for the welfare, safety and security of the student during his/her stay.
-To give the student reasonable and regular access to the bathroom and laundry facilities.
-To maintain a close liaison with the studentβs school and so be in a position to help resolve any problems that the student may encounter during his/her stay.
-To respect the studentβs different cultural background and be sensitive to the needs of the student.
Terms and conditions
*
I/We have read and understood the terms and conditions and I/we accept them.
In these conditions βYouβ means the host family and βWeβ or βUsβ means Country Cousins Ltd.
Country Cousins acts in all circumstances as an intermediary between guests and hosts on the basis of the representation and undertakings contained in Country Cousinsβ published materials relating to any particular arrangement.
1. Please ensure that you meet the below criteria:
You are willing to accept students into your home, interact with them and treat them as part of the family and no other guest of the same nationality shall be accepted at the same time.
You are willing to share the main communal living areas of your home with the students.
The bedrooms you wish to host students have a standard bed (not a futon, camp bed, mattress on floor), adequate drawer/hanging space and natural light and are in good overall condition, and are the same previously inspected by one of our Welfare and Accommodation officers. If you host a student from an UK independent school, you might need to provide a desk too.
2. Registration
The guest will not be asked to perform any domestic task other than to make his/her own bed.
Under the new regulations of the Children Act 1989, Country Cousins Ltd. has to forward the names of all adult household members to Social Services so that checks can be made by the appropriate departments.
3. Payments:
Payment for board and lodging will be made by Country Cousins after the first week of the stay.
Weekly rate for students with full board will be:
Language school students Β£18 per night (students spend most of the day at school in lessons and activities)
UK Independent schools on school holidays during academic year Β£28 per night. (These students stay with you 24/7 while on school holidays)
Lost cheques will not be re-issued until there has been a 6-month period after issuing the original. Spoiled Cheques will only be re-issued on receipt of the original cheque being returned to us. This is why we strongly advise all payments by BACS transfer direct to your account.
4. Cancellations:
In the unlikely event that βYouβ fail to meet the criteria stated above, we have the right to remove your student without prior notice and without further payment.
In the unlikely event of βYouβ requesting that your student be removed from your home before the end of their stay, Country Cousins Ltd will only be liable to pay for any complete nightβs stay within your home. If you have already received payment for the entire anticipated stay, then you will be liable for reimbursing Country Cousins Ltd.
In the unlikely event of βYour Studentβ requesting to be moved from your home before the end of their stay, for any of the verified reasons stated below: The family is not hosting to the standard that βWeβ expect, including accommodation, hygiene, and cleanliness.
Any other major issue that is brought to our attention.
We βCountry Cousins Ltdβ will feel that the move is justified and we will be liable to pay you for any complete nights stay within your home. If you have already received payment from us for the entire anticipated stay, then you will be liable for reimbursing us. Country Cousins Ltd will pay βYouβ one full week fee, if we feel that the move of a student / guest from your home is unjustified.
5. Liability:
Country Cousins Ltd. acts in all circumstances only as an intermediary between the host and the guest. In no event can we be considered responsible for:
any injury, accident, loss, damage, delay, inconvenience or expense of any kind whatsoever which may occur during the guestβs stay in the hostβs home or in any other connection with the arrangements made, damage caused by the guest to the person or property of the host or the hostβs family;
For for any complaint or legal action which may be brought against the guest by the host or the hostβs family or against the host or the hostβs family by the guest or the guestβs parents or guardians; or for any debt incurred to the host or the hostβs family, however arising; or for any expense or inconvenience caused to the host or the hostβs family through accident or illness of the guest, such expenses being the responsibility of the guest or the guestβs parents or guardians; or in the event of Country Cousins being unable to provide a suitable guest for the period of availability stated on the enrolment form; or by cancellation of the guestβs visit; or by arrival after or departure before the dates stated by us.
6. Data Protection Act 1998
I am aware that Country Cousins will create and maintain computer and paper records relating to my family and home and that these records will be in compliance with the principles of the Data Protection Act 1998.
I consent that my information may be used within Country Cousins and my address, home and family description may be sent to students booked to stay in my home.
I consent that my name, address and telephone number may be issued to other homestay providers who are hosting Country Cousins students for the purpose of safeguarding.
Consent
*
I (host carer) give permission for Country Cousins to complete a local authority check.
I give permission to the local authority to share information that is deemed necessary to safeguard a child.
Name
*
First
Last
CHILDREN ACT 1989
Declaration Regarding Suitability to Work with Children
Additional occupants
Surname
First Names
Date of Birth
Add
Remove
Please list below any additional occupants over the age of 16 who have not been previously mentioned.
Have you ever been convicted of any offence against a child?
*
Have you ever been convicted of any offence against a child?
Yes
No
Have you ever had a child removed from your care by the order of a court?
*
Have you ever had a child removed from your care by the order of a court?
Yes
No
Have you ever had a prohibition imposed on you at any time?
*
Have you ever had a prohibition imposed on you at any time?
Yes
No
Have you ever been disqualified from acting as a foster parent?
*
Have you ever been disqualified from acting as a foster parent?
Yes
No
Have you ever been proved negligent whilst supervising under 18s on activities/courses organised by any other organisation?
*
Have you ever been proved negligent whilst supervising under 18s on activities/courses organised by any other organisation?
Yes
No
If you have answered βyesβ to any of the above questions, please supply the dates and circumstances:
Consent
*
I agree to the local authority arranging for police records to be checked for previous convictions of me, the staff member/group leader /host family, subject to the Rehabilitation of the Offenders Act 1974 and exemption orders.
* To be signed by the main named host
Section 70(a) of the Children Act 1989 provides that a person who makes any statement in this notice or gives information that he knows to be false or misleading shall be guilty of an offense and liable on summary conviction to a fine not exceeding level 5.
HOMESTAY FIRE RISK ASSESSMENT
A homestay provider is legally required to have a fire risk assessment to comply with fire safety law. Please complete this Risk Assessment for the risks within the home. Consider how a fire could be started, and explain what you are doing to minimise this possibility.
Kitchen / Cooking hazard or risk
Kitchen risk level
*
High Risk (unaccptable risk)
Medium Risk (requires action)
Low Risk (action if necessary)
Very Low Risk (no action required)
Level of Risk
Electrical Fault hazard or risk
*
Electrical fault risk level
*
High Risk (unaccptable risk)
Medium Risk (requires action)
Low Risk (action if necessary)
Very Low Risk (no action required)
Level of Risk
Smoking hazard or risk
*
Smoking hazard risk level
*
High Risk (unaccptable risk)
Medium Risk (requires action)
Low Risk (action if necessary)
Very Low Risk (no action required)
Level of Risk
Gas Appliances hazard or risk
*
Gas Appliances risk level
*
High Risk (unaccptable risk)
Medium Risk (requires action)
Low Risk (action if necessary)
Very Low Risk (no action required)
Level of Risk
Other hazards or risks
*
Other hazard risk level
*
High Risk (unaccptable risk)
Medium Risk (requires action)
Low Risk (action if necessary)
Very Low Risk (no action required)
Level of Risk
Evacuation
*
Write below instructions on how to exit the house in the event of a fire. Provide an alternative should this route not be possible. Inform all guests upon arrival.
Smoke detectors
Location in house
Date tested
Add
Remove
Tested every 3 months by host
Remaining actions
Action
Date to be completed
Add
Remove
What actions remain to be done? e.g. New batteries in alarm.
Name
First
Last
Δ
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