Homestay Only

Register Online
Attention: Before completing this form, please read Registration & Payment Procedure carefully and thoroughly.


Personal Information


* First name       * Last name  

* Street Address     * City  

State in the U.S. State or region outside of the U.S.

* Country     Zip code

* Phone number     Cell number

* Email address    * Gender  

* Date of birth           * Place of Birth  

* Passport #   * Passport valid until        

* Nationality (citizenship)  

* Emergency contact person   * Relationship  

* Emergency contact number  

Name of your university   Please indicate your major

Employment History:(Job Title, Employer, Dates of Employment, etc.)


Name of medical insurance carrier:

Policy number:

Homestay Information

* Where would you prefer to do a homestay ?(Please indicate name of the university you are going to attend).
 

* Please select your desired price range  

* Arrival date       * Length of Stay  

* Do you smoke?  

* Do you mind a family with a preschool-age child ? 

* Do you mind a family with pets? 

* Are you interested and qualified to apply for our Teach and Stay Program(Please note: a $80/week administration fee is required to apply for free homestay)

* If teach and stay exchange is not available, would you still be willing to join our program? 

Please list any allergies, health problems, or foods that you can not eat:


Please indicate a few of your hobbies or special interests, we will try to match these with a host family:


Use the space provided below for any additional detail about yourself.


How did you hear about Lotus? Please specify:

TERMS AND CONDITIONS

By initialing below,I agree that I have read the program information, understand and accept the conditions under which these programs will be conducted, particularly those which apply to the program cost, and refund policy. I understand that the program cost includes administrative expenses, and hereby release Lotus, their agents, employees or representatives from all actions suits, claims, or liability for damages arising out of my participation in the program. I confirm that I have also read the "Notice of Understanding Between Participant and Lotus"
* Please type initial here  

Type Verify Code:  

Before submitting the registration form, please print it out for your record. If you can't make on-line submission, please fax the printed form to us at 408-884-2429 or download the registration form, fill it out and send it to reg@lotuseducation.org.

 

 


 
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