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The English Language Centre
Level 9, 115 Grenfell Street
The University of Adelaide
SA 5005 Australia

Telephone: +61 8 8313 4777
Facsimile: +61 8 8313 4411
Email: elc@adelaide.edu.au

Host Family Survey

*indicates required fields

Personal Details
Family Name/s*
No longer able to host We are no longer able to commit to hosting.
Please tick the appropriate boxes below to indicate your preference/s to host an international student (some dates and student numbers are subject to change).
UniversityCountryDates
Duration (weeks)
No. of students
Korea 3 January - 6 February 5 15
Korea 3 January - 6 February 5 20
Korea 3 January - 6 February 5 20
Keimyung University Korea 3 January - 6 February 5 20
Chosun University Korea 3 January - 6 February 5 20
Pusan National University Korea 11 January - 5 February 4 17
Kansai University (Economics) Japan 6 February - 13 March 5 40
Waseda University Japan 6 February - 22 February 2 36
Nagoya University of Foreign Studies Japan 13 February - 8 March 3 15
St Margaret's Junior College Japan 13 February - 14 March 4 20
Okayama University Japan 14 February - 20 March 5 20
Kansai University (International Office) Japan 14 February - 13 March 4 20
Kobe Shoin University Japan 14 February - 13 March 4 15
Kobe Gakuin University Japan 13 February - 6 March 3 20
Japan 7 March - 27 March 3 12
Any University  
Preferences
Gender Preference No preference
Male
Female
Would you be willing to host a Muslim student? Yes
I would like more information
No
Would you be available to host more than one student during the summer period ie. 2 different nationalities. Yes
No
Will you be hosting other international students during Jan/Feb/Mar? Yes
No
If yes, please provide detail about the students below.
Student 1
Gender Male
Female
Nationality
Student 2
Gender Male
Female
Nationality
Student 3
Gender Male
Female
Nationality
Please complete the information below to ensure we have your correct details:
Family Name/s*
Address*
Suburb*
State South Australia
Post code*
Email/s (preferred)*

(H)

(W)

Contact numbers Home*
Work
Mobile
How many rooms do you have available for hosting students?

Internet Access is ESSENTIAL
What internet access do you have available for students?

 Dial up
Broadband
Wireless
None
No pets
Dog/s

Please provide details of the number of dogs and if they are inside or outside dogs.

Cat/s

Please provide details of the number of cats and if they are inside or outside cats.

Other, please specify
Any further information or comments