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HOMESTAY APPLICATION FORM

Please complete ALL sections of the Homestay Application Form in order to avoid delays or errors in processing your application. Thank you for choosing Language Achievement Canada.

 
Name and Address
Family Name: First Name:
School Attending : Age:
Course: English/French:  
Gender: Male Female  
   
Address:
City: Prov/State:
Country: Postal Code:
Telephone: Fax:
Email:
My Homestay Preferences
I require airport transfer services: Arrival Only
Arrival & Departure
Not Required

My arrival flight information in Ottawa: Month:
Date:
    Year:
       
    Airline:
    Flight #:
    Arrival Time:
       
    Important: Please send us your flight itinerary even if you do not require Airport Transfers. Failure to provide this information may result in Airport Transfer delays or cancellations with refund, or your host family may not be home upon your arrival.

I require the following Homestay Plan: Full Plan (21 meals/week)
Breakfast Plan (7 breakfasts/week)

My Homestay Check-In date is: Month:
Date:
Year:

My Homestay Check-Out date is: Month:
Date:
Year:

I would like my Homestay family to include: Family with young children ( 12 years or younger)
Family with teenagers ( 13 years or older)
Adult(s) with no children
No preference

I prefer the following for sharing a home with other students: Other students are acceptable
No other students who speak my language
No other students in my home
No preference

I prefer the following room type: Single Room Prefered
Shared Room acceptable
No preference

My Lifestyle Information
I smoke tobacco: No
Light Smoker
Heavy Smoker

I drink alcohol: No
Yes
Sometimes

I can cook my own meals: Yes
No
If No, I am willing to learn:
Yes
No

I can do my own laundry: Yes
No
If No, I am willing to learn:
Yes
No

My preference for pets in my Homestay: Pets are fine
No Cats
No Dogs
No Birds
No pets of any kind

I have a special diet: No
Vegetarian
Kosher/Hallal
Other (Please describe below)

I have allergies: No
Yes (Please describe below)

I have illnesses: No
Yes (Please describe below)

I take medications: No
Yes (Please describe below)

Highest level of education: High School
College/University

My occupation is: Student
Government Employee
Military
Embassy Employee
Company Employee/Executive
Parent at home
Other (please describe below)

My hobbies, interests, activities etc:

My host family should know this about my personality, character etc:

The most important qualities my host family should have are?
       

Homestay Application Conditions
I, the student (or parent/legal guardian) have read the terms and conditions of LAC - Language Achievement Canada and I agree to abide by them. I understand that LAC - Language Achievement Canada cannot guarantee that all my homestay preferences will be fully met.

I will send my payment by:
       
Internet Signature (Name of student):
       
Date:
       
       


 
   

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