(*)required field

1. STUDENT DETAILS:

TITLE :(Mr/Miss)(*)

FAMILY NAME:(*)

GIVEN NAME(S):(*)

Preferred English Name (if applicable):

DATE OF BIRTH:(*)

Age:(*)

NATIONALITY:(*)

Do You Smoke?:(*)

Yes No

2. SCHOOL DETAILS:

School/University you will attend: (please state which campus)(*)

Course to be studied: (ELICOS, DIPLOMA, BACHELOR)(*)

3. ARRIVAL DETAILS:

Date of Arrival:

Time Of Arrival:

01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM

Flight No:

Is transport required from airport to homestay:(*)

Yes No

(if "YES" please complite our online Aiport Pick Up Form)

4. HOMESTAY INFORMATION:

How long do you require homestay accommodation?
(min. 4 weeks unless by prior arrangement):(*)

Any food allergies or dietary requirements?:

Smoking:(*)

Yes No Outside

Pat:(*)

Yes No Outside

Children:(*)

Yes No Don't Mind

Overseas Students:(*)

Yes No Don't Mind

Any other comments:

Terms and Conditions:
• This form must be submitted at least 2 weeks before confirmed
  arrival date.
• The minimum stay with a host family is four weeks.
• Students must pay A+J STUDENT CARE SERVICES
  a 4 weeks homestay fee plus a Homestay Placement Fee
  of $235 in advance.
• 2 weeks writen notice must be given to the homestay if you   intend to leave.
• Cancellation should be lodged in writing at least 24 hours prior
  to your arrival OR a cancellation fee of 2 weeks homestay fees will   be incurred.
• Homestay Placement fees are non refundable or transferable to
  another person.

I have read, and agreed with, the Terms and Conditions listed above:

Yes(*)

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