Homelingua application form

All parts of the form marked with * must be completed or your application cannot be sent. Please give us as much information as possible to help us place you with the most suitable teacher.

Personal Details
Title*	Mr Mrs Ms
First Name(s)*
Family Name*
Address*
Post Code*
Country*
Home Telephone*
Work Telephone
Fax
E-Mail*
Emergency Contact Name, Address and telephone during your stay*
Date of Birth*
Marital status	Married Single
Occupation*
Company or School Name
Nationality*
Native Language*
What are your Hobbies and Interests?*
Do you have any Physical Disability that may affect your stay in any way? *	Yes No
If Yes, please explain

Course Details
Course Name*
Number of lessons per week (if applicable)	20 25 30 35
If your course is Homelingua Plus Alpha or Homelingua Senior;
Number of English lessons per week
Number of Alpha activities per week
If your course is Homelingua Plus Alpha or Homelingua Senior
Please indicate your choice of Alpha activities. (see here for ideas on activities)	Alpha Activity		Times per week

Course Start Date (Check In)*	Day Month Year
Course Finish Date (Check Out)*	Day Month Year

Accommodation
Preferred Location
Choice 1*
Choice 2*
Choice 3*
Do you have any allergies?*	Yes No
If yes, please give details
Do you smoke?*	Yes No
Please note that most of our Accommodation is no smoking. It may be difficult to find a home where you can smoke inside the house.
What kind of home do you prefer to stay in? *	With Children	No Children	Don't Mind
	With Pets	No Pets	Don't Mind
	In the Town	Countryside	Don't Mind

Your English Level
Do you study English at the moment?*	Yes No
If Yes, how long have you studied for?	6 Months 1 Year More than 1 year
Do you use English in your work?	Yes No
Please estimate your level of English.*	Speaking
	Listening
	Reading
	Writing
	Grammar
What area of your English do you want to develop?
Other Information: Please tell us anything else about yourself that will help us select the best tutor for you.


Arrival and Departure
Do you want Homelingua to arrange a driver/taxi to meet you on arrival and/or departure?	On Arrival Only Arrival and Departure Not required
What is your Arrival Date in the UK?
What is your departure date from the UK?
I have read and understand the Terms and Conditions of booking*