First Name
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Last Name
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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
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City
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Province / State
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Country
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Postal / Zip Code
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Phone Number
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E-mail Address
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Agent's Name (optional)
Agent's E-mail Address (optional)
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Father's Name
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Mother's Name
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Parent's Address (if different from above)
Parent's Phone Number
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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.)
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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.
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I agree to follow the Student Responsibilities, and accept the Terms and Conditions:
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