Home Programs Promotions About us Photo gallery Location Contact Blog
 
   
 
 
 
 
 
 
 
  Why choose Connect English?

Check out our new promotions

 

  
 
 
 
  Contact Us

4560 Alvarado Canyon Road, Suite 2B San Diego, CA 92120 View map

Phone: (619) 283-2811
Fax: (619) 283-2866

e-mail: info@connectenglishsandiego.com

MSN: connectenglishsandiego@live.com

  
     
 
 
 
Homestay Request Form
   
   
 
Last/Family Name First/Given Name Middle Name
   
Date of Birth: Day   Year 
   
Gender: Male   Female
   
Country of Citizenship:
   
Do you smoke? Yes   No
   
Passport Number:
   
Arrival Date: Day   Year 
   
How long will you stay?:
   
Visa Type:
   
I want a:
(check one)		 a. Single room, breakfast only

b. Single room, breakfast and dinner

c. *Double room, breakfast only

d. *Double room, breakfast and dinner

*must book in pairs
   
Address in your home country:
   
Are there any types of animals that you do not want in your home?

 		 Yes   No
If yes, which type(s) do you not want?
   
What are your hobbies?
   
Do you dislike any particular foods? (If yes please describe foods that you do not like)
   
Do you have any allergies? (If yes please describe them)
   
Will you drive a car? Yes   No
   
Do you have any special requests for the family?
   
   
Emergency Contact in U.S.
Name
   
Relationship
   
Phone (home)
   
Phone (work)
   
Emergency Contact in Home Country
Name
   
Relationship
   
Phone (home)
   
Phone (work)
   
Arrival/Departure Information
Arrival Date Day   Year 
   
Time
   
Airline
   
Flight Number
   
Departure Date Day   Year 
   
Length of Stay
   
Airport Pick up:
Would you like airport pick-up service ($70 one way)? Yes   No
   
Would you like an airport drop off ($70 one way)? Yes   No
   
I certify the above information is true and correct:
   
Signature of Applicant
   
 
 

 

 
 
 


© Connect English Language Institute. English School, San Diego, California. Contact us  03/01/2011