Given name(s)  *

Date of birth  *

Gender  *  male   female 

Phone  *

Fax

Email  *

Nationality  *

NZ Phone

Occupation

Course applied for  *

Course starting date

Course length  4 weeks   12 weeks   24 weeks   48 weeks   other 

if other please specify length of study in number of weeks

Insurance: proof of insurance for the duration of the course is required  *

State of Health  Good   Disability or illness (please specify) 

Allergy  Yes   No 

Allergy to what?

Smoker  Yes   No 

Accomodation  *

I prefer  A family without children   A family without children 

Food I can't eat

Hobbies I enjoy