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Homestay Service Request Form

Please fill-out this homestay request form and we will process your request. Please fill in the form in ENGLISH. Thank you.


Campus :
Campus : Rosemead Torrance

Student Information:
Family Name :
First Name :
Middle Name :
Telephone :
E-Mail :
Date of Birth :

Month 		/
Day 		/
Year
Age :
Gender : Male Female
Address in Your Country :

Emergency Contact Information - A contact person who is living in Los Angeles ( Optional )
Person's Name :
Telephone :   ( EX: xxx-xxx-xxxx )
E-mail :
Address in Los Angeles :

Arrival Information : ( If known )
Airline :
Flight Number :
Date :
Time :

Questions :
Do you smoke ? Yes No
If "yes", can you smoke outdoors only ? Yes No
Do you drink alcohol ? Yes No
Is family with children OK? Yes No
Is family with pets OK? Yes No
Do you want to include 2 meals? Yes No
Who do you want your food prepared by? Your Host Family Yourself
What form of transportation will you use? Car Bus
Other :
How long will you stay in Los Angeles?
Which date will be your first day of homestay ?
Which date will be your final day of homestay ? ( If known )
Other necessary information
( please let us know if you have any special needs or requests ) :