Homestay application form

Family name
Given name(s)
Email address
Physical address
Daytime telephone
Evening telephone
Fax
Nationality
Date of birth
Gender
Do you require a homestay to be arranged for you?
This will be in a comfortable room of your own with a family who will provide all your meals and arrange laundry etc
Cost: $(NZ) 240 per week = $10,800 [45weeks]
Are you a vegetarian?
Is there any food you cannot eat?
If 'yes', please specify below
Do you require any special foods?
If 'yes', please specify below
Do you require special religious observances?
If 'yes', please specify below
Do you have any allergies?
If 'yes', please specify below
Are you happy with younger children?
Are you happy with cats or dogs in your home?
Would you prefer to be placed with a non smoking family?
What are your hobbies and interests? E.g. do you require use of a piano etc?
Please explain any other needs or requirements, and make comments about what you would like in a homestay.

Please Note - special dietary requirements may incur an additional payment to the homestay provider.
Phone: 03 455 0113        Email:        Address: 2 Shore Street, DUNEDIN
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