Please answer all required fields (marked with * ) then Submit Application

*Full Homestay (Breakfast & Dinner) B&B (Breakfast)

*First Name: * Last Name:

*Gender: Male Female

*Address:

Postal Code: *City: State

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Telephone *Email

*Date of Birth: / /19 (month/day/year) *Religion:

*Nationality: *Native Language:

*Level of English: Low Intermediate Advanced

*Arrival Date: / /20 (month/day/year)

Time: AM PM , Airline Flight No:

*Will you need personal airport pick up service? Yes No

*Length of stay in Homestays Weeks Months Year Years , Will you have a car? Yes No

While in Atlanta what school/Program will you attend?

*Profession/Student (Course of Study)

*Hobbies/Interest

Check your Preferences:

*Family type : Couple Single Family with children   *Family with Pets: Dogs Cats No Pets   *Family that smokes? Yes No No Preference   *Family that drinks alcohol Yes No No Preference

*Do you Smoke? Yes No

*Do you drink alcohol? Yes No

*Are you currently under the care of a Doctor? Yes No

*Do you have any special needs? Yes No

List needs as well as any allegies or any foods you cannot eat:

*Emergency contact (include name/address/phone number and relationship to you)

* I understand that neither the host nor Atlanta Homestays is responsible for my health or safety

Date: