First Name:
Last Name:
Street Name:
City:		Postal Code
Telephone:		Home:    Cel:  Work:
Fax:		Home:    Work:
E-mail:
FARM INFORMATION
Farm Type:
Description on Farm: Please include types and numbers of animals, crops, land situation, location, etc.
Please describe jobs that you would have the Farmstay Participant doing:
Working Conditions (days/week, hours, etc.)
Members of Household (including yourself)   Name (First / Last) Relationship Occupation Birth Date (MM/DD/YYYY)
Hobbies & Interests (active & passive):
To what degree would the worker participate in your family's activities?
Please give a general description of your meal routine (breakfast, lunch, dinner). How much help do you expect in preparation and clean-up?		Breakfast : Lunch : Dinner : Expectation for Preparationa and Clean up:
What are your family's rules about cigarette smoking and alcohol drinking? Would you be willing to take a smoker if he/she went outside to smoke?		Smoke: Alcohol: Accept smoker if they smoke outside only:
What pets do you have?
How many participants can you accommodate?		Private   Shared
Please state preference:		Male  Female  No Preference
How long would you like one Farmstay to last?
Please indicate the best time and worst time of the year to host a Farmstay Participant.
Have you ever hosted Japanese or other foreigners before?
Please provide extra information that you think is significant.
Where did you hear about Contact Canada?
Please give two references (including full names, telephone numbers, and relationships) Name Relationship Telephone
I AGREE CONTACT CANADA OR ITS AGENTS DO NOT ASSUME RESPONSIBILITY FOR ANY DAMAGE OR LOSS IN ANY FORM.
DATE(MM/DD/YYYY):  APPLICANT'S NAME:
Check your information and then press the SUBMIT button to send to Contact Canada