Application to be a Residential Caregiver - Pukekohe High School Development

Please complete the form below if you would like to apply to become a Home Stay family.

If you are an approved Homestay family for another School/Institution, can you please give us the name of the School here

Parent 1 Details

Parent 1 Name(Required)

First Name(s) Family Name

Parent 1 Date of Birth(Required)

MM slash DD slash YYYY

Parent 1 Email(Required)

Parent 1 Mobile Phone(Required)

Home Phone

Work Phone

Parent 1 Occupation(Required)

Is the Occupation(Required)

Full Time

Part Time

Residential Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Postal Address (if different from above)

Street Address Address Line 2 City ZIP / Postal Code

Parent 2 Details

Parent 2 Name

First Name(s) Family Name

Parent 2 Date of Birth

MM slash DD slash YYYY

Parent 2 Email

Parent 2 Mobile Phone

Home Phone

Work Phone

Parent 2 Occupation

Is the Occupation

Full Time

Part Time

Emergency Contact

Emergency Contact Person Name(Required)

Emergency Phone Number(Required)

Medical Information

Does any member of the family have an existing medical condition that we need to be aware of? E.g. asthma, epilepsy etc. If yes, please note the condition and the family member who has the condition

Please provide your family Doctor's details as international students will normally be taken to this Doctor if needed

Household Members

CHILD 1

Name

First Name(s) Family Name

Date of Birth

MM slash DD slash YYYY

Age

School/Tertiary Institution Attended

CHILD 2

Name

First Name(s) Family Name

Date of Birth

MM slash DD slash YYYY

Age

School/Tertiary Institution Attended

CHILD 3

Name

First Name(s) Family Name

Date of Birth

MM slash DD slash YYYY

Age

School/Tertiary Institution Attended

CHILD 4

Name

First Name(s) Family Name

Date of Birth

MM slash DD slash YYYY

Age

School/Tertiary Institution Attended

Household Pets

Do you have pets? If so describe them here. Are they inside or outside animals?

Household Information

Total Number of Bedrooms

Number of Spare Bedrooms

Number of Bathrooms

Family Information

Does your family follow a particular diet? E.g. vegetarian, kosher, vegan etc. If so, please advise us

What languages are spoken in your home?

If your family has hosted international students previously with another provider, please give us details here:

Will your insurance policy cover any breakages or damage caused by your international student?

Yes

Does any member of the household smoke/vape?

Yes

What facilities does your household have?

Unlimited Internet Access

Limited Internet Access

No Internet Access

Near the Beach

Near a Mall

Near a corner store/dairy

Piano

Pool

Spa Pool

Tennis Court

Bicycles

Water Sports

Other

You selected Other, please specify

Please tick below what hobbies and activities your family participate in

Board Games

Cooking/Baking

Soccer/Football

Badminton

Basketball

Going to the beach

Pool Swimming

Surfing

Going to the Cinema

Religious participation e.g. temple, church

Cricket

Fishing

Gardening

Music Concerts

Theatre

Bush Walks

Water Sports

10 Pin Bowling

Please list any other activities here

Please give us a brief description of a typical week in your household (activities, sports, work, school, hobbies, after school activities etc):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

International Student Preferences

Number of students you would like to host at any given time (maximum 2)

Male or Female Preferred

Preferred Age (usually 13-18)

Preference is Short Term (3 weeks-1 Term) or Long Term (2+ Terms)

Would you be available for emergency accommodation? (where students need to move from their current homestay immediately)

Yes

Are you willing to collect your student from Auckland International Airport when they first arrive into NZ?

Yes

Would your family be willing to host an international student if they were in NZ over the Christmas holiday?

Yes

International Student Arrangements

How will your student get to School each day and home again?

Walk (how long will it take?)

School Bus (number?)

Be Driven (by whom?)

Public Bus

Other (please state)

Please provide further transport details:

What arrangements will be made for your student after School? Students who are under 14yos can not be left unsupervised and need to have someone at least 14 years old at home with them.

Which family member(s) will help the student with their homework if needed?

Can you detail how your family will offer your student a welcoming family atmosphere and hospitable experience?

Describe what your family will do with your student on a typical weekend?

Are you happy to take your student on family outings and/or let your student meet their friends etc in the weekends?

Safety Checks

As part of its obligations under The Education (Pastoral Care of International Students) Code of Practice 2016, Pukekohe High School, is required to complete a safety check of residential caregivers (Clause 26 (1) (b) of the Code).

NZQA expects that a police or criminal check on all persons aged 18 years and over living in accommodation where international students under 18 years old are being hosted. If there are members of the family that are turning 18 years old during an international student stay in the house, the Police Vet will need to be carried out for them too.

Please have all family members and other persons living on the property aged 18 years old, sign the following declaration:

Police Vetting Declaration I hereby give permission for Pukekohe High School to request a police vet:

Name

First Last

Signature

Name

First Last

Signature

Name

First Last

Signature

Referees

Please nominate two referees (not immediate family) who can provide information on your suitability to care for an international student in your home. One must be your current or previous employer, professional body or registration authority. If you have provided residential care before, the person or organisation who employed you in that situation should be one of your referees.

Referee Name

Contact Phone

Best time to contact

Referee Name

Contact Phone

Best time to contact

Bank Account Details

Bank Name and Branch

Bank Account Number

Declaration

I declare that this information is true and complete to the best of my knowledge

Signature (by the main applicant to host an international student)