Leir Education Host Family Application

Host Mother Section
Host Mother*

First NameLast Name
Upload Passport or Driving licence*

Cancelof
Host Mothers Occupation*
Date of Birth*

DayMonthYear
Date
Phone Number*

CodePhone Number
Contact Email*

Confirmation Emailexample@example.com
Marital Status*

MarriedCohabitingSeparatedDivorcedSingle ParentWidowed

Host Father Section
Host Fathers Name*

First NameLast Name
Upload Passport or Driving licence*

Cancelof
Date of Birth*

DayMonthYear
Date
Phone Number*

CodePhone Number
Contact email*

Confirmation Emailexample@example.com
Host Fathers Occupation*

General Home / Accomodation Section
Family Full Address*

Street Address

Street Address Line 2

TownCounty

Eir Code. If not known enter 0000Country
Is a working smoke Alarm fitted?*

YesNo
If 'Yes' is smoking allowed inside the home?*

YesNo
Do you host students from other organisations?*

YesNo
Please give details if "YES"

Childrens details
Do you have Children at home?*

YesNo
Childrens details
Please enter any other details you feel maybe relevant
Would you accommodate a student with special dietary requirements e.g. coeliac, vegetarian, diabetic etc.*

YesNo
What is your religion (Optional)
Would you be willing to host a student of a different religion?*

YesNo
Do you have pets?*

YesNo
If YES please specify

Do you have a computer or a laptop?*

YesNo
If yes would the student have use if it?*

YesNo
Do you have internet access?*

YesNo
If YES what security do you have in place?
Example: Child Protection Software

Please provide a brief description of your location e.g. town, estate, farm etc. and show the approximate distance to the nearest town or village etc.*
Is there any other important information regarding you or your family that you feel we should be aware of ? e.g. Heath issues etc. PLEASE NOTE ALL INFORMATION IS HELD IN THE STRICTEST CONFIDENCE - If none please put NONE*
Do you have plans to take any trips or holidays?*

YesNoOther
If the answer to the above is 'YES' please provide dates
Please provide any other information you think might be relevent

Safety Statement
I certify that all questions have been answered truthfully and see no reason at law or otherwise as to why my family or I should not be considered suitable to host a foreign student
Host Mother Signed:*
Name of Host Mother
Date*

DayMonthYear
Date
Host Father Signed:*
Name of Host Father
Date*

DayMonthYear
Date
Please note that all successful host family applicants will be required to read and sign our Host Family Terms, Conditions and Guidlines as well as a declaration before acceptance as a host family within our programme. In now way does the completion of this or any other application process by the potential hosts constitute any agreement between the potential hosts and or Leir Education and or its directors.

The completion of this application is part of a selection process and in no way binds Leir Education or any of its directors to any agreement or third party. Leir Education reserve the complete right to refuse, decline, agree or except any potential hosts at its disscretion.

Should you be assigned a student and the student cancels their application prior to the commencement of the programme Leir Education cannot guarantee a replacement student.

Terms, Conditions and Declarations
A host family who accommodates a student or students for Leir Education Limited from here on is referred to as Leir, must agree but are not limited to the basic terms and conditions as outlined below.

• To provide sufficient, suitable and appropriate accommodation as required to meet standards as set and requested by Leir Education Limited.

• Never to have more than one student of any mother tongue in their home at any one time, unless authorized in writing by Leir Education Limited.

• Never to host a student from another agency while hosting a student from Leir.

• To provide at minimum a breakfast, Lunch and a cooked evening meal on a daily basis, the student will be expected to sit at the meal table with the family at all meals and take part in all family activities as if a member of the family.

• To meet the student at the pick-up point on the arrival day and to deliver the student to the departure point in good time on the departure day.

• To take the student to and collect him/her from school or the meeting point as required.

• To take appropriate action if a student needs to visit doctor, hospital or dentist etc.

Garda Vetting is compulsory & required to host a Student
Have you or partner ever been Garda Vetted?*

YesNo
If you selected Yes please upload document received form the relative body
Document Upload

Cancelof
Do you require Garda Vetting through Leir?*

YesNo
If you selected Yes please upload document received form the relative body

Privacy Statement
Declaration II
Host Mothers Name*

First NameLast Name
Have you, or any member of your family who may or may not still live at home or who may come into contact with a Leir Student ever
Had a child removed from your care by order of the courts?*

YesNo
Been convicted of any affence against a child?*

YesNo
Had a child removed from your care by any other agency?*

YesNo
Had your rights and duties with respect to any child vested a local authority?*

YesNo
If you answered "YES" to any of the above questions please supply full details here and if required on a seperate sheet paper
I declare that I have no criminal record or court case pending against me, and there is no reason why I should not be considered a person suitable to work with children.
Host Mother - Electronic signature*

First NameLast Name

Host Fathers Name*

First NameLast Name
Have you, or any member of your family who may or may not still live at home or whom may come into contact with a Leir Student ever.....
Had a child removed from your care by order of the courts?*

YesNo
Been convicted of any affence against a child?*

YesNo
Had a child removed from your care by any other agency?*

YesNo
Had your rights and duties with respect to any child vested a local authority?*

YesNo
If you answered "YES" to any of the above questions please supply full details here and if required on a seperate sheet paper
I declare that I have no criminal record or court case pending against me, and there is no reason why I should not be considered a person suitable to work with children.
Host Father - Electronic signature*

First NameLast Name

I, the undersigned, declare that I have read the Leir Education Host Family Accommodation Guide in every part.

I agree to have a student staying in my house as a paying guest. I accept the rate of pay as outlined.

I will make every effort to ensure that the students staying in my home will feel welcome and I will include them in family meals, conversations and activities as I would normally etc.

I agree that I must collect students from the meeting point on their arrival and drop them off to the meeting point on their departure. If I am unable to do so, I will make alternative arrangements in agreement with or as maybe as advised by Leir.

If a student causes any trouble, or is sick, I agree to notify Leir Education by telephone and also to email peter@leir.ie

If the student is obliged, for any reason, to leave my home before the end of their stay, I will accept the amount of money corresponding to the actual length of stay (number of nights).

I agree to provide students with a minimum of three meals each day and I will ensure that all meals provided are varied, nutritiously sound and balanced.

I understand that I must provide adequate private space for student study with appropriate facilities, that I must provide access to shower/bath facilities each day and laundry facilities on a weekly basis. As part of the agreement, host families are required to wash the students’ clothes, including items such as jeans and jumpers.

I understand that I must ensure that the student reaches the school on the first and every day required (and when necessary, I will bring them to school myself).

I understand and agree that I will accommodate no more than One student at the same time from any school or source. With the only exception being allowed for and by Leir Education in writing.

By signing this form, I accept the Host Family Accommodation Regulations of Leir Education Ltd. Failure to comply with these will result in removal of students and payment being forfeited as well the possibility of leagal action against us.
Host Mother Signature

Clear
To be signed in person when meeting
Host Father Signature

Clear
To be signed in person when meeting

This document forms part of the application form

NON DISCLOSURE AGREEMENT

As an alliance partner or individual involved in a business relationship with Leir Education Limited in whatever capacity as may be agreed (hereafter referred to as "the Company"),

I ____________________________________________________as a RESRESENTATIVE OF SELF, SPOUCE, PARTNER & OR PARTNER(S) and FAMILY (i.e. individual acting without a registered or known company or business name) which is inclusive of all direct or indirect ASSOCIATES, EMPLOYEES, RERESENTITIVES and is INCLUSIVE OF ALL FAMILY MEMBERS as a whole (hereafter referred to as "The PARTNER") agrees to not at any time disclose or use, either before, during or after its relationship with the company, any information, knowledge or data concerning the business of the Company including but not exclusive to its products, concepts, payments, methods, contacts, Esther individual or company (whether or not in writing) which the Partner shall receive or develop during its business relationship with the company, which is or maybe considered confidential or proprietary by the Company, or which relates to its trade, secrets, products, concepts or relative in any way to its business.

I agree without any reservation not to enter into any other arrangement, agreement or form of business directly or indirectly with any students, friends, family or associates of such persons either personally, professionally or through any other company or organisation which may interfere, exclude or disrupt "the Company" and its business and if contacted by any third party agree to inform "the Company" of all details of such contact by all parties either directly or indirectly.

NON DISCLOSURE AGREEMENT

“The Company” shall retain complete ownership of all information and contacts which is deemed relevant to its day-to-day running, development, future and the organisation inclusive of its directors and or owners. Such information, knowledge or data may consist of the following, which is by example only: processes, know-how designs, drawings, diagrams, formulae, test data, applications, documents, accounting or financial data, computer programs, pricing or salary, marketing data, business plans and strategies, negotiations and contracts, research, customer or vendor lists, customer information, inventions and discoveries, concepts and theories (and shall hereafter collectively be referred to as “Proprietary Information”).

The Partner agrees to promptly inform the Company of all discoveries, inventions, improvements, ideas and innovations relating to the business relationship, whether patentable or not and whether protected by trademark or copyright or not, which the Partner may invent, discover, originate, make or conceive, either by itself or jointly with others, during the time that the Partner is involved in a business relationship with the Company and The Partner hereby assigns to the Company a non-exclusive right to use any and all such discoveries, inventions, improvements, ideas and innovations for the duration of the business relationship. Whenever requested by the Company, the Partner will execute any and all documents which it (the Company) deems necessary to protect its interests in such matters.

NON DISCLOSURE AGREEMENT

The Partner further agrees that upon termination of any business relationship with the Company, the Partner shall promptly return any and all documents or other media containing Proprietary Information, or relating thereto, to the Company and or its business or products. The Partner agrees that it is obligated not to disclose or to use Proprietary Information, and it’s obligation to return records and tangible property containing such Proprietary Information, also extends to such types of information, knowledge or data of customers of the Company, suppliers to the Company or other third parties, who may have disclosed or entrusted the same to the Company or to the Partner in the course of the business of the Company. The Partner agrees to comply with any security measures requested by such third parties to prevent the loss of their confidential information.

This Agreement shall be binding upon my successors, heirs, assigns and personal representatives and shall be for the benefit of the successors and assigns of the Company. If a dispute arises concerning this Agreement and any action is filed, the prevailing parties shall be entitled to reasonable attorney’s fees and costs.

I understand that my ongoing business relationship with the Company is contingent upon my compliance with this Agreement.

The below is to be signed in person when meeting.

Signed:______________________________

Print Name:___________________________

Signed: ______________________________

Print Name: __________________________

As an individual, on behalf of self, group, family, company or organisation

Date: ________________________
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Leir Education is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website, then you can be assured that it will only be used as stated within the terms of our privacy policy, which can be viewed here: 'Privacy Policy'

For further information regarding our 'Sign-up' and our Host Family 'Terms and Conditions please see the below links:
- https://leireducation.com/host-family-sign-up-terms-agreement
- https://leireducation.com/host-family-terms-and-conditions-of-use
In order to submit this form you need to offer specific consent*

Yes
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Host Mother Section

Host Father Section

General Home / Accomodation Section

Childrens details

Student Preference Section

Safety Statement

Terms, Conditions and Declarations

Garda Vetting is compulsory & required to host a Student

Privacy Statement

Declaration II