Student Application

Family Name: _______________________________

First Name: ________________________________

Sex: M____ F_____

Birth date: _____________________________ Age: _______________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Phone No: ____________________________ Fax: _________________________________

Email: ________________________________ Passport ______________________________

Length of stay in Canada? _______________ Where in Canada? ________________________

Date/Time 0f Arrival_____________________ Flight No: _____________________________

Do you require Airport Pick up? __________________________________________________________________________
 

School or College attending? ____________ Do you want us to register you? ______________

      Name          Relationship                          Occupation                                              Age

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

Medical Information:

Do you have any chronic medical illness? Yes_________________ No________________

If yes, please explain: ______________________________________________________

Are you currently under Doctors care? Yes_________________ No__________________

If yes, please explain: ______________________________________________________

Are you allergic to anything? Yes__________ No________

(E.g.: medicine, smoking, food or pets) If yes, please explain: _________________________

Do you smoke? Yes________________ No________________

Personal Characteristics:

Are you?

______Energetic    ______ Quiet

______ Sociable     ______ Calm

______ Outgoing   ______ Reserved

______ Like to spend a lot of quiet time at home ______ Enjoy a very social life

Music: ___________________________________________________________________

Sports: ___________________________________________________________________

Hobbies: _________________________________________________________________

Do you prefer a host family with children _______ other student's _________None ________

Comments/Information:

_________________________________________________________________________

How did you hear about us? ___________________________________________________

I UNDERSTAND THAT BOWERS HOMESTAY SERVICES WILL SELECT A FAMILY FROM THOSE AVAILABLE, BASED ON THE INFORMATION THAT I HAVE PROVIDED AND THAT THEY CANNOT GUARANTEE THAT ALL OF MY PERSONAL PREFERENCES WILL BE MET. I ALSO UNDERSTAND THAT BOWERS HOMESTAY SERVICES IS NOT LIABLE FOR ANY LOSS OR DAMAGES.

________________________________ ___________________________

Student’s Signature                                                           Date

Your home away from home…

IMPORTANT:  Please note instructions at http://www.canadahomestay.com/appconfirmation.htm