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Student Application

Agent/Agency Name :
Telephone :
Mobile :
Student First Name :
SurName :
Home Address :
Nationality :
City :
Country :
Contact Agent or School Councilor :
Email Address :
Date of Birth :
Age Now :
Arrival Date :
Flight :
Name of School/University :
Please indicate days and times you will attend:
Courses you will take :
When will your course start and for how long ?
How long do you wish to stay with your HELP family ?
Do you smoke ?	Yes No
Do you have a special dietary needs? If yes please explain?
Do you like animals ?	Yes No
Do you require religious observances ?	Yes No
Do you drink alcohol ?	Yes No
Do you have health problems ?
Are you object to small children in the house? What ages ?
Do you like children ? What ages ?	Yes No
Can you do domestic work ?	Yes No
Can you cook ?	Yes No
Do you have any special requests (eg piano, computer) ?
Do you have any special skills (swimming) ?
Do you want to drive in NZ ?
What is your level of English (1-10) ?
Own bedroom/bathroom :	Yes No
Computer use :	Yes No
Car use :	Yes No
FOR HELP FAMILY / CO-ORDINATOR USE
HELP Family Name :
Family Address :
Phone :
Fax :
How many children do you have ?
Family Email :
Facilities Offered
Own bedroom/bathroom :	Yes No
Computer use :	Yes No
Car use :	Yes No
Must be Signed by all Parties
Student Agree :	Yes No
Student's Agent agree :	Yes No
Host family agree :	Yes No