HOMESTAY HOST FAMILY APPLICATION
Please complete as best as possible and then press the SUBMIT button to send the form to Contact Canada.
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First Name:  
Last Name:   
Street Address:
 
City:
  Postal Code
Telephone:   Home:    Cel:  Work: 
Fax:   Home:    Work: 
E-mail:  

Members of Household (including yourself)
 
Name
(First / Last)		 Relationship Occupation Birth Date
(MM/DD/YYYY)

Place of employment :  
Parents' first language and other languages :  
Family's hobbies and interests:  
To what degree would the student 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?

 

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?

 

What pets do you have?

 

Please describe the quickest Public Transportation route(Bus or Subway) to the downtown area from your house (include bus #(s) & approx. length of time).

 
Please indicate the type of your home:  
How many students can you accommodate?   Private   Shared
Please state preference:   Male  Female  No Preference
Acceptable Student Age:    14-16  17-19  20-24  Older  No preference

Please indicate the most convenient and most inconvenient time of year:

 
Please indicate how long you would be willing to host a student (You may check more than 1 box):   less than 1 week 1-3 weeks 1-3 months
3-6 months more than 6 months
Please indicate the size of your room(s): Room 1
Room 2
Room 3
Do you have an Internet access at home ? Yes No

Would you accept the idea of international visitors using YOUR computer for Internet access ?

Yes No
Would you accept the idea of international visitors using their own computer for Internet access through your home phone line ? Yes No

Have you hosted any foreign students before? How many? Please comment.

 
Please list any homestay programs that you have hosted for in the past or currently host for : 1.
2.
3.
Please give your reason for wanting to host an overseas student.
 
Please provide extra information that you think is significant on Homestay:  
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