Name of Agent Email address of Agent Name of Agent's Contact person Student details Family name Given name Date Of Birth Age Gender MaleFemaleTransgenderGender neutralNon-binaryOther Nationality What Provence/City do you reside in Student Email address Parent Email address (Required for invoicing purposes) Do you smoke: YesNo Date of Arrival Time of Arrival Flight Number Homestay Start Date How many weeks do you require homestay? (4 weeks is the minimum stay) Do you require transport from the airport to the homestay? (This is compulsory for under 18 students) YesNo Do you have any food allergies and/or dietary requirements? Details: Please list your Food Allergies and/or Dietary Requirements here. Any Medical Details we need to know about? Please list your Medical details here. Homestay Information Please note you will be placed in the best homestay available at the time of your application Smoking YesNo Other students YesNo Other Children YesNo Pets YesNo Message
