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.
|