PO Box 6751 GCMC, Bundall, Queensland, 9726, Australia
Student's Personal Information:
First Name: Last Name:
Address:
City: State / Prov.:
Country: Zip / Postal Code:
Telephone: Fax:
Email Address: Sex: Male:    Female:
Nationality: Birth Date: (MM/DD/YYYY)

Emergency Contact Information:
Contact Name: Relationship:
Tel No (daytime): Tel No (evening):

Homestay Characteristics:
Please choose the amount of weekly hours of private English tuition you would like: None (Homestay Only): 10 hrs/wk:   15 hrs/wk:
Are there any foods that you cannot eat? Yes:   No:
If yes, please specify which foods:  
   
Do you have any allergies? Yes:   No:
If yes, please specify  
   

Do you require special medical treatment?

 Yes:   No:
If yes, please specify  
   

Do you have medical insurance?

Yes:   No:
   
Do you want to live with pets? Yes:   No:   Does Not Matter:
   

Do you care if your Host family has dogs?

 Yes:   No:   Does Not Matter:
   
Do you care if your Host family has cats? Yes:   No:   Does Not Matter:
   
Please list your preference (number 1 will indicate your first choice).:

 - I would like to live with a family with children.

 Choice #:

 - I would like to live with a family without children.

 Choice #:
 - I would like to live in a single Host home. Choice #:
   
Do you want to stay with a Host family with other international students? Yes:   No:   Does Not Matter:
   
Do you smoke? Yes:   No:
   
Do you care if the members in your Host family smoke? Yes:   No:   Does Not Matter:
   

Character:
Please select as many characteristics that apply to you.
Hold down the CTRL key to select more than one.
Do you like to spend a lot of time at home?: Yes:   No:   Sometimes:

Do you enjoy a very active social life?:

 Yes:   No:
 
What are your hobbies?
 
What sports activities do you like to watch or to participate in?
   

Level of English Written: 

Level of English Spoken: 

 

What is your profession or area of study?
Are you interested in participating in our social activities? Yes:   No:

I would love to visit Theme Parks like Dream World and Sea World:

 Yes:   No:

Would you require your host teacher to accompany you on such excursions (extra charges apply)?:

 Yes:   No:
 

Homestay period:
Number of nights:    
Date From: (MM/DD/YYYY) Date to: (MM/DD/YYYY)
 
Arrival Information:
Airport pick-up required:   Yes:   No: Airport drop-off required:    Yes:   No:
Arrival Date (MM/DD/YYYY): Airline:
Flight No:

Arrival Time:

  Please indicate AM or PM
Passport Number:    

Additional Comments or Concerns:
 
How did you find out about our company?
 
     

© copyright 2004 - Dakkoala Homestay Pty. Ltd., Gold Coast, Queensland Australia