Student Application Form


Family Name
 
A value is required.
Given Name(s)

A value is required.

Gender:

 
Please make a selection.


Date of Birth:

Month
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Day
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Year
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Number of Brothers and Sisters
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Home Address

An entry is required.

City
 
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Province / State

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Country
 
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Postal / Zip Code

A value is required.

Phone Number
 
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E-mail Address

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Agent's Name (optional)
 

Agent's E-mail Address (optional)
Invalid format.

Father's Family Name
 
A value is required.
Father's Given Name(s)

A value is required.
Mother's Family Name
 
A value is required.
Mother's Given Name(s)

A value is required.

Parent's Address (if different from above)

Parent's Phone Number
A value is required. Invalid format.

If under 18, please add parents' date of birth for custodianship


Do you have any medical conditions?

Do you take any medication?

Do you have any allergies?

Do you follow a special diet? (Such as vegetarian.)

Do you smoke?

 
Please make a selection.

Which school will you be attending in Canada? (include address)

When are you arriving in Canada?

When are you leaving Canada?

Do you want Homestay Select Inc. to provide you with a custodian?

Tell us about yourself, your hobbies and interests.

An entry is required.

I agree to follow the Student Responsibilities, and accept the Terms and Conditions:

 
Please make a selection.