Homestay Application (General)

Personal Information
Please note that the symbol [ * ] indicates a required field. Applications submitted without this information will not be processed.

Family Name: *

First Name: *

Gender: *

Date of Birth: * 19 Age: years

Address:

City:

State/Province:

Country:

Zip/Postal Code:

Telephone: *

Facsimile:

Email: *

Emergency Contact:

Emergency Telephone:

Family Characteristics

Parent's Name:

Day Phone:

Parent's Email:

Do you have siblings? No Siblings
Older Siblings
Younger Siblings
Older and Younger Siblings

Agent Information

Name of Agency:

Contact Name:

Contact Phone:

Contact Fax:

Contact Email:

Arrival and Departure Information

Arrival Date: * Time:

Arrival Airline: Flight #:

Return Date:

Airport Pick-up: Yes (See Fee Schedule)
No

School Information

Are you attending school? Yes
No

Name of School:

Start Date:

Homestay Preferences

Homestay Type: (See Fee Schedule)

Basic plus full board (3 meals per day)

Basic plus half board (2 meals per day)

Homestay Add-ons: (See Fee Schedule)

High Speed Internet Access (student provides laptop or computer)

Proximity to School (located within 30 minutes of school)

Private Bathroom (exclusive use of bathroom facilities)

Monitored Custodial Guardianship (for minors aged 15-18 years)

Family Preference:

Family with no children

Family with young children

Family with teenage children

No preference

Pet preference:

I prefer no pets

I prefer cats only

I prefer dogs only

No preference

Do you smoke?

No

Yes (Some restrictions may apply as many families are non-smoking)

Do you require special meals?

No

Halal (Some limitations may apply)

Vegetarian (Some limitations may apply)

Medical Information

Please list any allergies, special medications, or health problems:

Additional Placement Considerations

Hobbies, Interests, etc:

Additional Comments: