Accommodation Request

NB: All Information submitted is strictly confidential and will not be used for any other purpose than to assess your accommodation requirements

APPLICANT DETAILS


First Name

Last Name

Your Email

Age

Sex male female

Nationality

Occupation

Phone

Fax

Postal Address

DATES


Desired Length of Stay

Arrival Date

Departure Date

Flight Number

Airline

Airport Pickup Required Yes No

A$120 - ONE WAY ONLY (Personalised Service)

ACCOMMODATION REQUIRED


Rooms Twin Single Other

Bathroom Ensuite Private Bath Shared bath

Other Requirements, Facilities and Local Amenities Desired

Please list any special requirements you might have or desire
eg. Swimming pool, Beach Access, Parks, Proximity to Transport and Shops etc

PREFERENCES


Preferred Location

Parking Yes No
Is a car parking space required at the host family residence?

Family with Children Yes No Either

Family with Pets Yes No Either

Food Bed and Breakfast All Meals provided Room only - No food

Private Cooking Facilities Desired Yes No

Food Requirements or Restrictions

Any special food requirements or restrictions - e.g. vegetarian or gluten free

Are you a Smoker Yes No

 

Are Smokers in Household OK? Yes No

 

MEDICAL


Medical Needs Yes No
Do you have any allergies or special medical needs?

 

Medical Details

GENERAL


Comments and Special Requests
Please use the space above for any extra comments or special requests you may have

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