SHOJI Australia
Host Family Application Form

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Please fill in the applicable field in the form below and submit to us to register as a host family.
Fields marked * must be completed.
Information you provide is strictly confidential. Shoji Australia will not give your information to any third parties without your permission.
If you have any problems with the form please contact us.

For School Based Hosting Programs, please use school program host family application form HERE.

Family Information

*Currently we only accept applications within WA.

Resident's information

Applicant (occupant 1) - Must be adult member of the family

Male Female

Working with Children Check (WWCC)

Yes

(dd/mm/yyyy)

Occupant 2

Male Female

Working with Children Check (WWCC)

Yes

(dd/mm/yyyy)

Occupant 3

Male Female

Working with Children Check (WWCC)

Yes

(dd/mm/yyyy)

Occupant 4

Male Female

Working with Children Check (WWCC)

Yes

(dd/mm/yyyy)

Occupant 5

Male Female

Occupant 6

Male Female

(DD/MM/YYYY)

 

Police clearance
Does any member of your household have a Federal Police Clearance?

Occupant 1 Occupant 2 Occupant 3 Occupant 4

 

Language & Religion

Yes No

Yes No

Transport / Access

How long does it take to walk to:

mins

mins

Household Info

(Large or Small? Inside or Outside?)

Student's access to facilities

Does student have access to the following facilities?

Own bedroom Own bathroom Own desk Own TV Swimming Pool Cable TV Use of laundry

Preferences

Up to 4 weeks Up to 3 month Long term Flexible on request

Under 18 Over 18 Parent & Child

History

Yes No

Notes

ReferEes

Please supply the names and contact details of 2 non-family members who would be willing to be as a personal referee for your family if required.

Survey

Declaration

I certify that the information presented in this form and on any attachments to it is true, complete and correct to the best of my knowledge.

 

 

 

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