R.O.S.E. - Rural Organization for Social Elevation

Section 1: Student details and contact information

Given Names:

Family Name: (Mr, Mrs, Miss)

Number / Street:

Suburb / City:

Postcode:

Country:

Telephone:

Fax:

Email Address:

Date of birth (DD/MM/YYYY)

Your Gender: Male Female

Agent Contact Details

Company Name

Telephone Number

Contact Name

Emergency Contact Details

Name

Telephone Number

Section 2: Course Information

Name of course 1

Name of course 2

Start date (DD/MM/YYYY)

Duration

Campus

Section 3: Airport Reception

Do you require airport pick up? Yes No

Delhi Arrival Date (DD/MM/YYYY)

Delh Arrival Time (AM/PM)

Airline Flight Number

Are you arriving with a relative or friend who is not a ROSE student? Yes No
Note - Non ROSE students must pay directly to the driver for their airport pick-up. You will be advised of the cost of the pick-up when you receive your confirmation.

Section 4: Pre- Allocated Homestay

How long do you plan to stay in homestay for? weeks

We need some personal information about you in order to find a suitable homestay.

Age

Level of English
Beginner Acceptable Good

Smoker?
Yes No

Hobbies and Interests

Religion

Languages Spoken

Have you travelled overseas before?

Yes - Where?

Do you have any medical condition (eg asthma, allergies) or disability?

Yes - What?

Is there any food you do not eat?

Homestay Preferences:

No children
Children under 12 years
Children over 12 years
No pets

No dogs
No cats
Single room
Twin share room (single sex only)

Any other information?