Homestay Application

City
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Marital Status
- Single
- Married
- Divorced
Country of Citizenship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Place of Birth*
Email*
Enter Email Confirm Email
Phone
Fax
Emergency Contact
Emergency Contact Name
Relationship
Emergency Contact Phone
Emergency Contact Email

School Information
Enrollment Start Date
MM slash DD slash YYYY
Enrollment End Date
MM slash DD slash YYYY
Name of School
Location (City, State)
Travel Information
Arrival Date
MM slash DD slash YYYY
Arrival Time

: Hours

Minutes

AM/PM
Airport
Airline
Flight Number
Flight Origin
Do you require airport pickup?
- Yes
- No
Will you have the use of an automobile?
- Yes
- No
Reservation
To reserve your accommodation, we require a one-time, non-refundable placement fee of $195. This fee guarantees your placement. You may pay your placement fee by credit card, wire transfer or bank draft. Once you submit this form, we will contact you to make payment arrangements.
By clicking below, you are certifying that the information provided above is complete and accurate. You are also acknowledging that you have read and understood our legal notices, and that you are at least 13 years old.
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Emergency Contact