First name(s):
Family name:
Spouse:
Date of birth: (dd/mm/yyyy)
Sex: male female
Home address:
Telephone contact number:
E mail address:
Nationality:
First language:
Religion:
What is your level of English: good fair poor
Name of person to contact in an emergency:
Their telephone number:
Have you travelled abroad before: YES NO
Have you travelled to the United Kingdom before: YES NO
Have you stayed with a host family before: YES NO
If `YES` please provide details:
What are your hobbies or interests:
How would you describe yourself: e.g. happy, outgoing, loner
Do you smoke: YES NO
Do you like animals: YES NO
Do you have any allergies: YES NO
If `YES` please provide details
Do you need to take any medication regularly: YES NO
If YES` what medicine and how often
Do you have any special dietary needs: YES NO
Accommodation Required
Bed and Breakfast / B&B and evening meal / accommodation only
(Delete the ones that do NOT apply)
Arrival date:
Departure date:
Arrival Airport:
Would you be prepared to share a room: YES NO
Details of study course in the United Kingdom
Name of school or College:
Address:
Telephone number:
Contact name:
Name of Course:
Course start date:
Course end date:
Any other information you want to provide:
please press submit button when completed