Vancouver Central Homestay

Student Homestay Application

Please Complete

NAME

FAMILY NAME

DATE OF BIRTH (dd/mm/yy)

Gender: Male Female

COUNTRY OF ORIGIN/BIRTH

PASSPORT NUMBER

Address

HOME ADDRESS

PHONE (incl. country & area codes)

E-MAIL ADDRESS

Emergency Contact Person

NAME

PHONE NUMBER

RELATION TO YOU

E-MAIL

English Programme

SCHOOL

LOCATION

START DATE (mm/yy)

END DATE (mm/yy)

LEVEL OF ENGLISH:	Pre-intermediate	Upper-intermediate
Beginner	Intermediate	Advanced

Homestay Information

START DATE (dd/mm/yy)

END DATE (dd/mm/yy)

Do you have special dietary requirements? If yes, please indicate below. (For example, are you a vegetarian?)

Do you have any allergies? If yes, please indicate them:

Do you take any medications. If yes, please indicate them:

Please list your Hobbies/Interests:

Can you live with pets? Yes No

Do you smoke? Yes No

Can you live with young children? Yes No

Airport Transfers

ARRIVAL DATE AND TIME

FLIGHT #

Do you need airport pickup? Yes No

Payment & Other Information

How will you pay?
Wire transfer
Bank draft or certified check

Enrolment conditions and refund policy
I have read and agree to be bound by the Terms & Conditions and the Payment and Refund Policy (select the checkbox if you agree)

My payment deposit will be made at least four weeks prior to the school start date (select the checkbox if you agree)

How did you hear about us? (e.g., search engine--please specify; friend, agent):

Your application will be reviewed and processed once received. At this point we will send you an invoice with our simple payment procedures.

Feel free to contact us at any time: we'd love to hear from you.
If you have questions, comments or suggestions, please drop us a line.
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www.vancouvercentralhomestay.com