Family Name: *

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Years of English studied:

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International Flight No.

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Arrival Date:

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Do you require "Meet and Greet" service at Queenstown Airport? Yes No

I will arrange my travel and medical insurance before coming to New Zealand.

I would like ABC College of English to arrange my travel and medical insurance.

I would like homestay accommodation:

I would like lodge accommodation:

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I would like information about: please select Hotel Motels Backpackers

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* If you wish to stay with a host family, please indicate your preferences below:

Do you smoke? Yes No (if yes, you may be asked to smoke outside)

Do you have any special dietary requirements? Yes No

Do you have any health problems? Yes No

If you have any other questions or comments, please use the space below: