Host Family Application Form Mother’s Name: Mother’s Surname: Occupation: Father’s Name: Father’s Surname: Occupation: Home Address: EIRCODE: Distance from Dungarvan Town (KM) Do you socialise with, or live near other host families? Yes No If Yes, name of other host family: Type of accommodation available: Single: Yes No Number of rooms: Ensuite: Yes No Twin Room Sharing: Yes No Number of rooms: Ensuite: Yes No How many students can you accommodate? Availability Student preference: Male Female No Preference July: 4 Weeks: Yes No 3 Weeks: Yes No August: 2 Weeks: Yes No Academic Year: Yes No Will you be hosting a student from another organization during this period? Yes No Name of Organization: Nationality of student: SPANISH ITALIAN FRENCH GERMAN OTHER DON’T KNOW Telephone Home: Telephone Mobile: Email address: Confirm Email address: Wifi: Yes No Parents: Interests and Hobbies: Bank details Name of account holder Address of Account holder: IBAN Children Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Gender: Male Female Name: DOB(dd/mm/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Living at home: Yes No Hobbies: Athletics Jogging Swimming Surfing Kayaking Sailing Horse ridding Tennis Table tennis Basketball Volleyball Football Martial arts Dancing Reading Listening to music Shopping Hanging out with friends Climbing Skiing Cooking Cinema Video games Cycling Rugby Golf Photography Other Pets Do You have pets? Yes No Inside: Small Dog Dog Cat Horse Pony Fish Bird Chickens Hamster Guinea Pig Other Outside: Small Dog Dog Cat Horse Pony Fish Bird Chickens Hamster Guinea Pig Other Agreements I HAVE READ AND I AGREE THE AGREEMENTS Agree Disagree Captcha code Change Code Our Families together to teach English
