Student/Traveller Name*
Student/Traveller Date of Birth*
Email*
Phone*
Program Start Date*
Program End Date*
Agency Name
Website
Phone
Fax
Email
Contact Name
Do you smoke?*—Please choose an option—YesNo
If Yes, are you prepared not to smoke in the House?*—Please choose an option—YesNo
Interest and Hobbies? (Please select the three activities that occupy most of your Time)*—Please choose an option—CookingFishingIce SkatingWood-workingBasketballHandballSkiingGardeningCampingHikingHorsebackRidingSwimmingOther—Please choose an option—CookingFishingIce SkatingWood-workingBasketballHandballSkiingGardeningCampingHikingHorsebackRidingSwimmingOther—Please choose an option—CookingFishingIce SkatingWood-workingBasketballHandballSkiingGardeningCampingHikingHorsebackRidingSwimmingOther
Please answer the following questions with complete sentences in the spaces below. Your answers to these questions will be read by our placement staff to help us determine the best possible placement for you, as well as by your prospective farm hosts once chosen, to give them a bit of an idea about you.
Why do you want to do farmstay in Canada?*
What do you expect to be your greatest challenge while doing farmstay?*
What do you expect to be your greatest reward while doing farmstay?*
Do you have any experience working on a farm or ranch, or doing related activities such as animal or care or agriculture?*
Describe your relationship with members of your family and friends.*
Describe any other special skills, abilities, education, or qualities that you think would be an asset while on the farm/ranch:*
Name(1)*
Age(1)*
Occupation(1)*
Relationship(1)*
Name(2)
Age(2)
Occupation(2)
Relationship(2)
Name(3)
Age(3)
Occupation(3)
Relationship(3)
Name(4)
Age(4)
Occupation(4)
Relationship(4)
Name(5)
Age(5)
Occupation(5)
Relationship(5)
Do you have any allergies? (If yes please specify)*
Do you have a special Diet? Eg. Vegetarian, lactose intolerant, etc.) (If yes please specify)*
Experiences: Describe any part time jobs or work experience you may have had.*
Have you ever lived outside your country? Yes (if yes, where?)*
Do you have any relatives or close friends in Canada? Yes (if yes, where?)*
Language(1)*
Years Studied(1)*
Proficiency(1)*
Language(2)
Years Studied(2)
Proficiency(2)
Language(3)
Years Studied(3)
Proficiency(3)
Airline
Flight Number
Arrival Date
Time of Arrival
am/pm—Please choose an option—ampm
Arriving From
Pick-up Required?*—Please choose an option—YesNo
Drop-off Required?*—Please choose an option—YesNo
