HOMESTAY STUDENT ACCOMMODATION REQUEST

STUDENT DETAILS

Name:  ________________________________________________ Male / Female Date of Birth:  ________________________________ Age:_________________________ Home Country Address:  ______________________________________________________________    ______________________________________________________________ Home Phone:  _________________________ Work Phone:________________________ Fax:  _________________________

NEW ZEALAND REPRESENTATIVE DETAILS

Name  ______________________________________________________________ Home Phone:  ______________________________________________________________

What career are you planning?   Religion?   Do you plan to return home in the term holidays?   Hobbies and Intrests   What Musical Instrument do you play?   What work do your parents do?   Do you mind living in a house with a pet?   Do you have any special food preferences or special diet?   Have you travelled to other countries before? (which ones)   Have you lived away from home before?   Are there any special items you plan to bring with you?

What career are you planning?  ______________________________________________________________ Do you smoke?  ______________________________________________________________ Do you mind living in a house with smokers?  ______________________________________________________________ Do you need any special health or medical needs (eg Malaria, Asthma, Allergies)?  ______________________________________________________________  ______________________________________________________________ Do you have any brothers or sisters?  Yes / No  Names:   1.______________________ Age:______     2.______________________ Age:______     3.______________________ Age:______     4.______________________ Age:______   Is there anything special you would like in a homestay?  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________ Tell us a little bit about yourself  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________ Is there any other request you would like to make?  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________  ______________________________________________________________ When do you plan to arrive in New Zealand?  Date:__________________ Flight:_________________ Time:__________ Signed:  (student)_____________________________________________________ Print Name in English:  (student)_____________________________________________________ Signed:  (parent)______________________________________________________ Print Name in English:  (parent)______________________________________________________ Date:  ______________________________________________________