Mr.      Mrs.      Ms.

Family Name:

First Name:

Male     Female             DOB DD/MM//YYYY

Employment:

Spouse's Last Name:

Spouses First Name:

Male     Female             DOB DD/MM/YYYY

Employment:

Home Address, City, Province, Postal Code

Phone No:          Fax:

Email:     Web Page

Nearest N/S Street:      
Nearest E/W Street:   

Route to Downtown:
 

Family members:

      Name       /        Relationship       /      Date of Birth

 1.

 2.

 3.

 4.

Number of Dependents:   

Language(s) Spoken:  

Preferences:     
Gender:  No Preference Female Male Age:  No Preference Teenagers Young Adults Adults Children   Religion: 

Household Pets:  None Large Dog(s) Small Dog(s) Cat(s) Bird(s) Reptile(s) Other Please Select

Do you allow smoking in your home?  No Smoking Smoking Outside Only Smoking Permitted Other Please Select

Type of Home  Please Select Apartment House Townhouse

No. of rooms available  Please Select 5 rooms or more 4 rooms 3 rooms 2 rooms 1 room Other       

Shared/Private Bath Please Select 1 Shared Bath 1 Private Bath 2 Shared Bath 1 Shared and 1 Private Bath More than 2 Shared Bath Other  

Parking Please Select No Parking Pay Parking Parking on Street Parking in Driveway Other Parking Options

Describe how you will be able to interact with your host student:

Your Interests: 
Sports:

Music:

Hobbies:

Other:

TV Programs:

Favorite Foods

Have you hosted international students before? If yes please explain

How did you hear about us? 

Please Select Friend Internet Email School Other

Please list two personal references (Name, Relationship, Phone Numbers):

BY SUBMITTING THIS ONLINE FORM, I UNDERSTAND THAT WHEN PLACED WITH A STUDENT BY BOWERS HOMESTAY SERVICES (BHS), I AM A HOST FAMILY REPRESENTED BY BHS AND UNDER NO CIRCUMSTANCES WILL MY FAMILY HOST STUDENTS FOR SCHOOLS IN WHICH I HAVE RECEIVED STUDENTS FROM BHS THAT HAVE NOT BEEN PLACED BY BHS.

I WILL PROVIDE A CLEAN FURNISHED PRIVATE ROOM, WARM AND HOSPITABLE ENVIRONMENT AND THE AGREED UPON BOARD. I ALSO UNDERSTAND THAT BOWERS HOMESTAY SERVICES IS NOT LIABLE FOR ANY DAMAGES OR LOSS CAUSED BY THE STUDENT.

I also understand that I will be paid for the time the student occupies the room only.