If you are submitting this form on behalf of a student please give your full contact details (Name, E-Mail, Address,
Telephone, Fax) and your relationship to the student;

Mr Mrs Miss Ms
Your First Name:
Your Family Name:

Your Complete Mail Address (include City, Province/State, Country, and Postal Code):

Telephone: E-Mail:

Your Homestay Preferences

1. Do you prefer a family: (check all that apply)
    With children Without children With teenagers Without teenagers
    No preference

2. Do you object to cigarette smoke?: Yes No (Home with smokers is O.K.)

3. Do you smoke?: Yes No

4. Do you like pets?: I Like Cats I Like Dogs No Pets No preference

5. Describe the type of family and home that would best suit you:

6. What date will you arrive at your Homestay:
    Year: Month: Day (Number):

7. What date will you leave your Homestay:
    Year: Month: Day (Number):

8. Do you wish to stay with a student from another country?: Yes No Note: If your answer is "Yes"
     then you will be placed with a student of the same gender that also speaks a language different from
     yours. You will always receive a private bedroom.

Last modified Thursday, 04-Sep-2008 13:34:12 PDT