REGISTRATION FORM

LIA ENGLISH ADVENTURE

A Homestay Program To Perth, Western Astra!"a
Name As In Passport :
Gender Female Male
Branch :
Student Card Number :
Place / Date of birth : :
Passport Number :
Address :
ome Phone No! :
Mobile No! :
e"mail :
#eli$ion :
%M%#G%NC& CA''
Parent(s Name #
Famil) #elationship Father / Mother * *circle
one
Address #
Phone / Mobile number #
SC++'
School Name #
School Address #
Class :
$% I D+ N+, -ish to li.e in a homesta) famil):
a.in$ pets
a.in$ children of m) a$e
a.in$ children a$ed under / )ears old
obbies and other thin$s I lo.e:
I don(t eat:
M) health conditions that need attention 0aller$ies1 etc!2 :
+ther special needs that need to be considered:
ere-ith -e enclose ad.ance pa)ment of ID# 314441444/ID# 514441444* as -ell as supportin$
documents 1 and -e understand all the pro.isions re$ardin$ cancellation applied b) the
or$ani6ers!
I1 the undersi$ned1 ha.e $i.en
the ri$ht data for re$istration form1 and a$reed to the rules set
Ac7no-led$ed b)
Participant
Name: 88888888888888888888
Date:
Parent
Name: 888888888888888888888888
Date:
Fax this form to 021-7948702,79190907 or email : tsbd_lia@ahoo!com
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