Host Family Application Form
Please fill out the following form in full

Personal Information
Title:	--select-- Mr. Mrs. Ms.
Name:
Occupation:
Spouse Name:
Spouse Occupation:
Home Information
Address:
City: *
Province/State:	------------- choose ------------- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico US Virgin Islands
Postal/Zip Code:
Country:	------------- choose ------------- Afghanistan Albania Algeria Western Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Republic Congo, Democratic Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Martinique Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent/Grenadines San Marino Saotome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Uganda Ukraine United Arab Emirates United Kingdom United States U.S. Virgin Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Sahara Yemen Yugoslavia Zambia Zimbabwe
How Can We Contact You?
Home Phone #:
Work Phone #:
E-Mail Address: *
Other Family Members
Family Member1:
Date of Birth:	(example: November 12, 1974)
Relationship:
Family Member2:
Date of Birth:	(example: November 12, 1974)
Relationship:
Family Member3:
Date of Birth:	(example: November 12, 1974)
Relationship:
Family Member4:
Date of Birth:	(example: November 12, 1974)
Relationship:
Describe The Room & In-Room Amenities
Please include information about availability of window, balcony, night table, lamp, desk, chair, closet, mirror, TV, clock radio, Internet access, computer, telephone, etc. Please include bed size (twin, double, queen).
Room Location:	(Basement, Main Floor, etc.)
Bathroom Facilities	Private   Shared
If shared, how many people share the bathroom:	--select-- 1 2 3 4 5 6 7 8 9
If more than 1 room is available, please describe the second room (number of beds, amenities, etc.). Also indicate location and if the bathroom is private or shared.
Do you have pets?	Yes   No
If yes, please describe:
Do you prefer male or female students?	Male   Female   Either
What age groups are you willing to host?	--select-- 8-13 13-17 18 and older
Do you smoke?	Yes   No
Do you accept smokers?	Yes   No
Please describe family activites and hobbies:
Are there frequent guests in your home?	Yes   No
If yes, please describe:
Languages Spoken At Home
Language 1:
Language 2:
Language 3:
Additional Information
Previous Homestay experience?	Yes   No
If yes, how many years?	--select-- 1 2 3 4 5 6 7 8 9 10 more than 10
Please provide us with any additional information
Please provide us with 2 references (personal, volunteer or employment). Please provide their name, relationship to applicant and a contact number. Reference 1 Reference 2
Homestay Program Disclaimer
This homestay disclaimer applies to all participants in this homestay program including hosts, applicants, affiliates, students and clients. I/We have read and understood the conditions and guidelines outlined on Hospitalité Canada website and it's applications. I/We understand that Hospitalité Canada including all company services, executives, employees and websites are acting as independent agents who are not guaranteeing the quality of the relationship between the homestay student and the host family, or between student and the educational institution, or other relationships. I/We understand and assume any and all risks related to my participation in this program, and I/We agree to release and hold harmless Hospitalité Canada and each of their respective employees, agents, and representatives from any and all liability of claims should any injury, loss, or damage occur during this hometay or any other service offered. I/We understand that if I/we participate in this program that I/we will purchase my/our own insurance whether medical, emergency, liability, damage, home, vehicle and/or any other types of insurance which may be necessary, should any claims, damages or penalties arise. Contact your insurance broker, travel agent, or insurance provider for more details. I/We undertand that Hospitalité Canada does not assume any responsibility for any injuries, losses, damages, problems or accidents that might occur during a homestay or a program. I/We further understand that any actions that take place among the homestay family, educational institution and student are not sanctioned by Hospitalité Canada nor do I hold Hospitalité Canada responsible for any reason.
Do you agree to the Student Guidelines? Yes   No
Do you and your representative accept the program disclaimer? Yes   No
By signing or submitting this application you acknowledge it true and binding.

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