Title*—Please choose an option—Mr.Ms.Mrs.
First Name*
Last Name*
Date of Birth*
Nationality*
Native Language*
Home Phone
Cell Phone
Email*
Emergency Phone
Agency Name
Counselor Name
Agency Email
Agency Phone
Check In*
Check Out*
Cats*—Please choose an option—YesNoNo Preference
Dogs*—Please choose an option—YesNoNo Preference
Kids*—Please choose an option—YesNoNo Preference
Smoking*—Please choose an option—YesNoOutside Only
Program*—Please choose an option—Homestay Single RoomHomestay Shared RoomExecutive StayRanchstay/Farmstay
Meal Plan*—Please choose an option—Full Board (3 meals/day)Half Board (Breakfast and Dinner)B & B (Breakfast Only)Roomstay (No Meals)
English Level—Please choose an option—BeginnerIntermediateAdvanced
Do You Smoke?—Please choose an option—YesNo
Medical Conditions? (Specify)
Allergies? (Specify)
Food Restrictions? (Specify)
List Your Favorite Activities, Hobbies & Interests
City Destination*—Please choose an option—VancouverVictoriaMontrealQuebec CityCalgaryEdmontonTorontoWindsor
School Name
School Start Date*
School End Date*
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
Applicants under 19 years of age only*—Please choose an option—NO - this applicant does not require Custodianship/another Custodian has already been arranged on behalf of this applicantYES - please arrange the custodianship on behalf of this applicant
Parent 1
First Name
Last Name
Date of Birth
Telephone
Street Address
City
State/Province
Country
Parent 2
Other Information
