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Personal Information |
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Title:
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Name:
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Address:
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City: *
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Province/State:
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Postal/Zip Code:
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Country:
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Home Phone #:
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Work Phone #:
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E-Mail Address:
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Gender
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Male
Female
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Nationality:
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Date of Birth:
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(example: November 12, 1974)
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Parent(s) Information (If under 18 yrs.) |
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Parent Name(s):
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Address:
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City:
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Province/State:
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Postal/Zip Code:
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Country:
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Phone:
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Email Address:
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Emergency Contact Information |
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Emergency Contace Name:
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Emergency Phone:
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Homestay Requirements |
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From what date:
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(example: November 12, 2006)
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To what date:
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(example: December 14, 2006)
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Homestay Choice
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With Meals
Without Meals
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Knowledge of English
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Beginner
Intermediate
Advanced
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Please list your hobbies:
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Which school will you be attending in Niagara:
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School Start Date:
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(example: December 14, 2006)
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Do you have a:
Student Visa
Visitor Visa
Resident Visa
Canadian Citizen
None
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Do you smoke?
YES
NO
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If yes, are you willing to smoke outside?
YES
NO
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Is a home with a pet acceptable?
YES
NO
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Do you have allergies?
YES
NO
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Do you have a physical disability?
YES
NO
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If yes, please explain:
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Do you require special medical treatment?
YES
NO
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If yes, please explain:
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Do you require a special diet?
YES
NO
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If yes, please explain:
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Additional comments, questions or information helpful in finding a host family:
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Travel Information |
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Would you like us to arrange airport transportation for you?
YES
NO
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Arrival Date:
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(example: December 14, 2006)
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Airport Name:
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Airline:
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Flight Number:
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Arrival Time:
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(ie. 00:00 hours - Ontario Local Time)
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Arriving From:
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Departure Date:
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(example: December 14, 2006)
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Airport Name:
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Airline:
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Flight Number:
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Departure Time:
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(ie. 00:00 hours - Ontario Local Time)
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Departing From:
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Additional Information |
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Would you like to purchase Medical Insurance through Hospitalité Canada?
Yes
No
If yes, we will email you a form
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Homestay Program Disclaimer |
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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.
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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.
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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. studentapp 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.
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Do you agree to the Student or Visitor Guidelines?
Yes
No
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Do you and your representative accept the program disclaimer?
Yes
No
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By signing or submitting this application you acknowledge it true and binding
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