Homestay Application Form – Demande d’hébergement chez l’habitant Δ Step 1 of 3 33% IMPORTANT NOTICE: Conditions apply to homestay placement. The conditions are detailed at the end of this form. I ACKNOWLEDGE that by proceeding to submit this form, I have agreed to the conditions.*AcknowledgedNom/Groupe (le cas échéant) Name/Group (if applicable)Sexe (Gender)Homme (Male)/ Femme (Female)Nom (Name)* Prénom (Given) Nom de famille (Family) Date de naissance (Date of Birth)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Adresse de résidence (Home Address) Adresse Ligne d’adresse 2 VIlle État / Province / Région Code postal AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Pays Email Téléphone (Phone)Date de début du séjour en famille d'accueil (Commencement Date of Homestay)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Durée du séjour en famille d'accueil (Length of Homestay)Please enter a number from 0 to 52.(en semaines) Combien d'autres membres de votre famille? (How many other members in your family?)*123456Informations du Membre 1 (Family Member 1 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherInformations du Membre 2 (Family Member 2 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherInformations du Membre 3 (Family Member 3 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherInformations du Membre 4 (Family Member 4 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherInformations du Membre 5 (Family Member 5 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherInformations du Membre 6 (Family Member 6 Details)Nom (Given Names) Prénom (Given) Nom de famille (Family) Âge (Age)Please enter a number from 0 to 100.Relation (Relationship)FatherMotherBrotherSisterProfession (Occupation)Accounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOther A propos de vous - About YouHobbies et intérêts? (Hobbies and interests?) Rugby Baseball Surfing Art Photography Reading Watching Movies Swimming Aerobics Listening to music Tennis Sailing Hiking Dancing Scuba Diving Golf Basketball Fishing Soccer Martial Arts Travel Cooking Playing Musical Instruments Comment décririez-vous votre niveau d'anglais? (How would you describe your English speaking ability?)Very GoodGoodFairPoorPréférez-vous une famille avec enfants? (Would you prefer a family with children?) Yes No Don't Mind Avez-vous une objection contre les animaux de compagnie? (Do you have any objection to pets?) Yes No Fumez-vous? (Do you smoke?) No Yes Yes, but I will smoke outside La plupart des familles australiennes interdisent de fumer à l'intérieur.Buvez-vous de l'alcool? (Do you drink alcohol?) Yes No Êtes-vous allergique à certaines nourritures? (Are you allergic to any food?) No Y a-t-il certaines nourritures que vous n'aimez pas? (Do you have any food dislikes?)Avez-vous des problèmes de santé? (Do you have any health problems?) No Yes Veuillez préciser (Please specify)Prenez-vous des médicaments? (Do you take any medication?) No Yes Veuillez préciser (Please specify)Aimez-vous les animaux? (Do you like animals?) Yes No Quels animaux aimez-vous? (Which animals do you like?) Bird Cat Dog Fish Comment vous décririez-vous? (How would you describe yourself?) sociable positive co-operative high achiever shy curious cheerful emotional affectionate nervous quiet serious Avez-vous déjà vécu loin de chez vous? (Have you ever lived away from home before?) Yes No Important Note: Homestay families are not necessarily Caucasian in a multinational Australia. You may see homestay families who have migrated into Australia and live as first generation or second generation Australians. They are required to speak English at all times to the students. The structure of the families is diverse including sole adult and with or without children. Many Australian families have pets. Please consider these facts when applying for homestay. Must be completed in English as this form will go to homestay family.*AcknowledgedWe will do our best to find homestay placements, but cannot guarantee that the student's preferences can be met, or that homestay families can be found.*AcknowledgedHomestay search will only begin after the full payment is received.*AcknowledgedFailure to disclose an existing medical condition may result in cancellation of the homestay placement and forfeiture of the homestay placement fee and homestay fees.*AcknowledgedCAPTCHA
