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: * 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 & Related Add-ons: (See Fee Schedule)

Private Bathroom (exclusive use of bathroom facilities)

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: