Formularz zamówienia na homestay

Please provide the following information.

LEAVE THIS FIELD EMPTY!

Name and surname:

Nationality:

School:

Course:

Phone:

Mobile:

E-mail:

Address in home country:

Date of birth: dd/mm/yy

Sex:

male
female

Level of English:

A home with children:

With children
Without children
Either

Meals?

No meals
With two meals per day
With three meals per day

Do you smoke?

Yes
No

Pets?

With pets
No pets
Either

Airport Pickup required?
If yes, provide details:

Accommodation start date: dd/mm/yy

Expected length of stay:

Additional requests: