Family Name: 

First Name:     

Sex:     Male      Female

Birth date:          Age:    
                                DD/MM/YYYY

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?         Yes       No

School or College attending?         
Do you want us to register you?    Yes     No

Family Members:

      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?  (E.g.: medicine, smoking, food or pets)    Yes      No  
If yes, please explain:    

Do you smoke?      Yes      No  

Personal Characteristics and Interests:  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  

Other Comments/Information:

How did you hear about us?

BY SUBMITTING THIS ONLINE FORM, 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.