Due to the current Pandemic of Coronavirus our office has been closed since March 23rd 2020 until further notice. We are happy to reply to all email enquires as soon as possible. Do find out about our online courses in the meantime by emailing us.

Completion of this form does not guarantees the allocation of students. All information given within this form will be used for the purpose of placing students and will always be treated as strictly confidential.

To download and fill in this form click this link.

 

    General

    Family Name:

    Address:

    Post Code:

    Telephone Number:

    Mobile Number:

    Email:

    Household Religion:

    Family Details:

    Husband's Details:

    First Name:

    Date of Birth:

    Profession:

    Wife's Details:

    First Name:

    Date of Birth:

    Profession:

    Children's Details:

    First Name #1:

    Date of Birth:

    Gender

    MaleFemale

    First Name #2:

    Date of Birth:

    Gender

    MaleFemale

    First Name #3:

    Date of Birth:

    Gender

    MaleFemale

    First Name #4:

    Date of Birth:

    Gender

    MaleFemale

    Other people living in the family

    First Name:

    Date of Birth:

    Profession:

    MaleFemale

    First Name:

    Date of Birth:

    Profession:

    MaleFemale

    Household details

    Please tick if you have any of the following items

    TelevisionVideo/TelevisionHi/FiComputerCarGardenMusical InstrumentsInternetPets

    Please Specify which type of pet you have

    Your Family's particular interests and hobbies:

    TennisFootballLiteratureStamp collectingHorse ridingCinemaTheatreSwimmingHandicraftsMusic

    Please specify other

    Does anyone in your family smoke ?

    Would you accept a student/guest who smoked ?

    Would you accept a vegetarian

    Number of spare bedrooms:

    How many students can you accommodate ?

    Student/Guest Preferred:

    MaleFemaleNo Preference

    Age:

    Do you have an Enhanced Disclosure Certificate from the new DBS (Disclosure and Barring service)?

    If the answer is yes please enter the information in this box:

    Issue date of Certificate:

    Reference number:

    If the answer is NO, Mercator can help you apply, as it is a requirement for hosting students under the age of 18.

    We would be grateful if you could introduce a friend who would like to take a student. (please obtain their permission to disclose their name and address to us)

    Name:

    Address:

    Post Code:

    Telephone Number:

    Children Act 1989 (Part XI)

    Declaration regarding suitability to provide accommodation for children

    To be completed by all members of the household over 16 years

    Full Name:

    Date of birth

    Home Address:

    Post Code:

    Have you ever: (Please tick)

    1. Been convicted of any offence against a child ?2. Had a child removed from your care by the order of a court ?3. Had a registration under Part X of the Children Act 1989 refused or cancelled (Childminding?)4.Had your rights and duties with respect to any child vested in a Local Authority ?5. Had a prohibition imposed on you at any time ?6. Been disqualified from acting as a foster parent ?

    If you have answered ticked yes to any of the above questions please supply the dates and circumstances:

    Section 70 (a) of the Children Act 1989 provides that a person who makes any statement in this notice or gives
    information which he knows to be false or misleading, shall be guilty of an offence and liable on summary conviction to
    a fine not exceeding level 5.
    I agree to the local authority arranging for police records to be checked for any previous convictions of myself, subject
    to the Rehabilitation of the Offenders Act 1974 and exemption orders.