City of Belmont and Adachi Exchange Program Homestay Application

About this student
This field is hidden when viewing the form
Is this student part of a study group?*
- Yes
- No
Study group name*
Study group contact person*
Type of Homestay required?*
- Full Board (3 meals per day)
- Traditional (Breakfast and dinner weekdays and 3 meals on weekends)
Student Name*
名前
First name Surname
Student email address*
メールアドレス
Student gender*
- Male o 男
- Female o 女
Student date of birth*
誕生日（日・月・年）
DD dash MM dash YYYY
When would you like accommodation from?
DD dash MM dash YYYY
When do you require accommodation to?
いつまで必要ですか？
DD dash MM dash YYYY

Some more student details
Let us know some of the finer details about you so we can match with the perfect home.
Your address
現住所

Street Address Address Line 2 City State / Province / Region Country
Your mobile phone number*
携帯電話番号

Adachi and City of Belmont Exchange Program