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HOMESTAY OF LONG BEACH
562-269-4606
Student Application
Name:
Relationship:
Phone:
Email:
Start Homestay date (MM/DD/YYYY):
End Homestay date (MM/DD/YYYY):
Meal Option:
Do you smoke?
Can you live with pets?
Can you live with children?
Do you have a special diet?
Do you have any allergies?
What are your hobbies?
English speaking skill?
Any special homestay requests?
Student First Name:
Student Last Name:
Gender:
Date of Birth (MM/DD/YYYY):
Address:
City:
State / Province:
Postal Code:
Country:
Phone:
Email:
School in US:
Are you an agent?
Agency Name:
Agency Email:
Arrival Date in US (MM/DD/YYYY):
Airline:
Flight Number:
Do you need transportation from the airport?
Name on Card:
Credit Card Number:
CCV (3 digit number on back):
Expiration Date (MM/YYYY):
Billing Address:
Billing City:
Billing State / Province:
Billing Postal Code:
Emergency Contact Information
Homestay Request
Payment Information
Your credit card will be immediately charged the application fee and security deposit for your homestay reservation, plus a 3.75% convenience fee.
Terms and Conditions
I have read and agree to all the Terms and Conditions.
Please click here to read our Terms and Conditions before you submit your application for processing
By clicking here, you agree to our Terms and Conditions as set forth. If you're an agent representing a student, you agree to inform the student of our Terms and Conditions when submitting their application for processing on their behalf.:
