Leeds Homestay Application Form

Date *

Today's date

YOUR DETAILS

Full name

Address

Street Address

Address continued *

Postal Code

City

Country

Your email address *

Your phone number

Gender MaleFemale

Age *

Citizenship *

Passport you travel with *

Country

Passport number

Person to contact in case of emergency *

Your relationship to contact

Contact phone number

If you are coming to Leeds to study where will you be studying *

Course of study *

Level of study

If you are not a student what is your occupation

If you are not a student what is your reason for visiting Leeds

eg: work, work experience, holiday etc

TRAVEL INFORMATION

Date of arrival in Leeds *

Time of arrival in Leeds

PERSONAL INFORMATION

Are you married *

Do you have children

Do you smoke *

What is your parent's occupation

What is your mother tongue *

The language you speak

Do you speak any other languages

Please describe your English language skills * ExcellentGoodAveragePoor

Please tell us anything about yourself that will help in placing you with a suitable host *

eg: interests, hobbies etc

Have you ever been away from home for an extended period of time * YesNo

If yes, where and when

Have you stayed in homestay accommodation before YesNo

Do you like pets * YesNoDon't mind

Do you have any dietary requirements *

eg: vegetarian or foods you dislike

What do you like doing in your leisure time *

HEALTH INFORMATION

Do you have any allergies * YesNo

If you are allergic to something, you will become ill when you come into contact with it.

If yes, please specify

Do you have any health problems * YesNo

If yes, please specify

Are you taking any medication YesNo

If yes, please specify

HOMESTAY INFORMATION

What date to you wish to start your homestay accommodation *

What date do you wish to finish your homestay accommodation *

Total weeks *

Which homestay level do you require BudgetStandardExecutive

Budget: £100 Standard: £110 Executive: £120

Do you have any special requirements for your host family *

Not all hosts are traditional families. Do you want a traditional family YesNoDon't mind

How did you find out about Leeds Homestay Services *

TERMS & CONDITIONS

I have read Leeds Homestay Services terms and conditions and agree to them. * YesNo

LHS Privacy Policy

The information you provide is used solely to process your information in order to enable us to provide you with our services. We collect and use your information lawfully according to the Data Protection Act 1998.

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