NOMINATED CARER HOMESTAY PROFILE

Student Name: ________________________

Genevieve Fung
Gender: Male/Female School : ____________________
Beverly hills girl high school

S520478
Student ID: ________________ Email: ___________________________ fungoilam7@gmail.com
Mobile: ____________________
0406799164

Nominated Carer (the Host):

Fung

Mr / Mrs / Miss / Ms/ Dr First name: .......................................... Family name: ..............................................

Ben

Address: …………………………………………………………..…………… Suburb………….…………………….…Postcode……………………

Unit18, 17-21webb st, Riverwood 2210

Telephone:……......................................................................... Mobile:..............................................................
Email:.......................................................................................................................... DOB:....................................

Total number of people living in the home: …………… Please list them all below:

First Name Family Name Gender Date of Birth Relationship to the Contact Number
Host
(dd / mm / yy)

Language spoken in the house: ………………………………………….…..…………………..

Cantonese

Number of bedrooms in the house: ……………………………………………………………. 3

Number of bathrooms in the house: ……………………………….………………………….. 3

I declare that the information provided above is true and correct

Name: ............................................... Signature: ..............................................date:............................

Office use only:

Carer Declaration Received
WWC Clearance Expiry:………………………………….
Inspection Date:……………………………………….….

PO Box 3059 Rhodes, NSW 2138

Tel: (61-2) 9325 6988
Email: info@ozhomestay.com.au Web: www.ozhomestay.com.au
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