Homestay Application Form: LAC - Language Achievement Canada

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
	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:

your home away from home ™