Personal Information
Name:
Home Address:
E-mail Address:
Gender:	male   female
Nationality:
Date of Birth:	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day January February March April May June July August September October November December Month Year
Passport Number:
Visa Classification:	Student    Visitor
Emergency Information
In case of emergency:
Contact Name:
Relationship:
Phone Number:
Home Address:
E-mail Address:
If you have a medical condition that might require a doctor’s attention immediately, please provide this information:
Education
Education in BC Please fill in the following 4 questions if you plan to attend a school in B.C.
Name of School in BC:
BC School Address:
Course of study:
How many weeks?
OR
Teacher - Tutoring CF Educational Services Ltd. provides teachers who will help you with your homework in English or other academic subjects. You may have a 1:1 private teacher-tutor or you may study with a friend. After you start school, you may use the the “Contact Us” key at any time, to tell us what kind of teacher-tutor you need. Would you like us to contact you about our teacher-tutors and mentors? Yes, please tell me about your tutoring service and mentors. No, I will not need a tutor or a mentor.
General Information This will help us match you to the right host family or roommate. Please complete either the Traditional Homestay or the Non-Traditional Homestay form.
** General Information for the Traditional Homestay **
I am interested in the Traditional Homestay
I would like the homestay with:	a private bathroom a shared bathroom
Special requests about food:
Do you smoke?	Yes, I smoke. No, I do not smoke.
Many Canadian families have a pet, such as a cat or a dog or hamster? Are all pets OK?	Yes, All Pets are ok. No, All Pets are not ok Pets not ok
Describe your personality.
Career goals
Interests in: Sports, or Hobbies. Other things?
Special Talents in: Music, Art, Crafts or anything else
** General Information for the Non-Traditional Homestay **
I am interested in the Non-Traditional Homestay
I would like the homestay with:	a fully furnished apartment a roommate a student house no preference
Describe your personality.
Career goals
Interests in: Sports, or Hobbies. Other things?
Special Talents in: Music, Art, Crafts or anything else
Do you smoke?	Yes, I smoke. No, I do not smoke.
Arrival & Departure Information
Date of Arrival:	Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2006 2007 2008 2009 2010
Time of Arrival:	By  Flight #: Name of Airline
Date of Departure:	Month January February March April May June July August September October November December   Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2006 2007 2008 2009 2010
Time of Departure:	By  Flight #: Name of Airline
Pick-Up and Drop-off Service:	I require airport pick-up service.       (Cost is $80.)
*How did you hear about CF Educational HOMESTAY Services Ltd? Friend School Agent Brochure Web Search
Please Enter any Questions or Comments you may have: By clicking the "Send Application" button below and submitting this questionnaire, I agree to release CF Educational Services Ltd. from any and all damages that I may suffer as a result of any loss, injury, or dispute arising out of the provision of homestay services. THANK YOU!