Host Family Application Form

Address

Family Surname(Required)

Address(Required)

Town(Required)

County(Required)

Eircode(Required)

Land Line Number

Dates and Bank Details

Planned Holidays / Nights Away(Required)

During the Year, Months you are available to Host(Required)

Bank Account Holder Name(Required)

IBAN(Required)

Applicant

Profile(Required)

Name(Required)

First Name Surname

Mobile Number(Required)

Email Address(Required)

Email Address Confirm Email Address

Nationality(Required)

Date of Birth(Required)

Occupation(Required)

Work Hours(Required)

Husband / Wife / Partner

Profile

Name

First Name Surname

Mobile Number

Email Address

Email Address Confirm Email Address

Nationality

Date of Birth

Occupation

Work Hours

Children's Details

How many children do you have?(Required)

Child 1 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Child 2 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Child 3 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Child 4 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Child 5 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Child 6 Name

Age

Date of Birth

Sex

Female

Male

Living at Home?

Yes

Alternative Emergency Number

Flight information for summer students is usually issued during the month of June, should your family take holidays atthat time, please give contact details of a family member / neighbour / friend who can take this information for you.

Name

Mobile Number

Name

Mobile Number

Family Hobbies / Talents

Musical Instruments

Crafts

Sports

Others

Home Details

Number of Bedrooms(Required)

Do you permit smoking in your home?(Required)

Yes

Do you have Internet in your home?(Required)

Yes

Do you have a car?(Required)

Yes

Do you have pets?(Required)

Yes, indoor

Yes, outdoor

Size of pets(Required)

Dog big

Dog small

Cat tiny

Other

Please specity type and size of pet

Rooms and type of Accommodation available

How many foreign students (Of different nationality) can you accommodate at any one time?(Required)

Bedroom 1 Size

Bed Type

Single

Bunk

Double

Sharing Room

Yes

Closet

Yes

Mirror

Yes

Table and Chair

Yes

Bedroom 2 Size

Bed Type

Single

Bunk

Double

Sharing Room

Yes

Closet

Yes

Mirror

Yes

Table and Chair

Yes

Bedroom 3 Size

Bed Type

Single

Bunk

Double

Sharing Room

Yes

Closet

Yes

Mirror

Yes

Table and Chair

Yes

Bedroom 4 Size

Bed Type

Single

Bunk

Double

Sharing Room

Yes

Closet

Yes

Mirror

Yes

Table and Chair

Yes

Programme Participation and Student Preference

Programme Participation(Required)

Academic Year Programme

Summer Activity Programme / 4 to 1

Ministay Programme

Student Preference(Required)

Preference Choice Cannot always guaranteed.

Student Age Preference(Required)

Preference Choice Cannot always guaranteed.

Allergies / Special Diets

If requested, could you provide meals for students with special needs? Please select special diets you can provide:

Special Diets Provided

Coeliac

Vegetarian

Diabetic

Dairy Free

None

Other Special Diet Provided, please specify

Is there a Family member with any of the above allergies / Special Diets?(Required)

Yes

Please specify which

Temporary Guest / Residents

It is quite acceptable that host families may have family relations or guest staying in their home while hosting a foreign student. Should this be the case, we would be grateful if you would list below any such guest, so that your student will know in advance who will be in the family home during their stay. If this information is not known when completing this application form, we would be grateful if you would inform a member of Staff in the Dalmac Office (01 843 1697) should you have a guest staying during the dates that your student will be in your home.

Number of guests staying during the dates that your student will be in your home?(Required)

Guest 1 Name

Sex

Female

Male

Age

Nationality

Relationship to Host Family

Guest 2 Name

Sex

Female

Male

Age

Nationality

Relationship to Host Family

Guest 3 Name

Sex

Female

Male

Age

Nationality

Relationship to Host Family

Guest 4 Name

Sex

Female

Male

Age

Nationality

Relationship to Host Family

Guest 5 Name

Sex

Female

Male

Age

Nationality

Relationship to Host Family

Acceptance and Signature

Dalmac Language School is recognised and approved by the Irish Department of Education & Science, it is necessary for all host families to complete and sign our official Host Family Application Form on a yearly basis. We will not be able to allocate students to you until we have a current application form.

I declare that I/We have read and accept the Dalmac Language Host Family Guidelines/Rules as explained in the Dalmac Language Information Leaflet.

Signature(Required)

This field is hidden when viewing the form

Date

All host families will be deemed to have agreed to these conditions, without variation, once a student placement has been communicated and accepted by the host family.