Home Stay Form

Personal Information
Last Name * : Given Name * :
Middle Name: Preferred Name:
Date of Birth: Sex:  
English Ability:    
Phone * : Fax:
Email * : Postal Code:
Home Stay Information
Home Stay Required:  
Start Date: End Date:
Preferred Area:        
Are home stay pets OK?    
Are home stay children OK?    
Do you smoke?  
Dietary Restrictions/medical Conditions:
List your interests, activities, etc.:
Special Requests Fees (In Canadian Dollars) - Payable to the third party
Home Stay placement fee (non-refundable) $150.00
Airport pick-up ($100 one-way)   Flight Number:
Health Insurance ($1.50 per day)  
Health Insurance Start Date: Health Insurance End Date:
Total Payment($):
Placement fee, airport pick up, insurance and one month home stay fee must be payable to the third party at the time of registration.