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.