Homestay Placement and International Students Services

Student and Visitor Application Form

Homestay Application

Please fill-out all aspects of this application. We require all information to be completed to the best of your knowledge. Should you have some missing information, please do not forget to forward missing information, as soon as possible, in an email. Here is Homestay Application, click on the print icon to print this application.

Agent Information
First Name:
Last Name:
Company Name:
E-Mail Address:
Student Information
First Name: *
Last Name: *
English Name (Optional):
City: *
Postal/Zip Code:
Home Phone #:
Work Phone #:
E-Mail Address:
Gender  Male   Female 
Date of Birth:
(example: November 12, 1974)
Parent(s) Information (If under 18 yrs.)
Parent Name(s):
Postal/Zip Code:
Email Address:
Emergency Contact Information
Emergency Contace Name:
Emergency Phone:
Homestay Requirements
From what date:
(example: November 12, 2006)
To what date:
(example: December 14, 2006)
Homestay Choice  With Meals   Without Meals
Knowledge of English  Beginner   Intermediate   Advanced  
Which school Board will you be attending in Niagara:
School Start Date:
(example: December 14, 2006)

Do you have a: Student Visa Visitor Visa Resident Visa
Canadian Citizen None  

Do you smoke? YES   NO 
If yes, are you willing to smoke outside? YES  NO 
Is a home with a pet acceptable? YES  NO 
Do you have allergies? YES   NO 

Do you have a physical disability?
If yes, please explain:

Do you require special medical treatment? YES  NO 
If yes, please explain:

Do you require a special diet? YES  NO 
If yes, please explain:

Personal Habits
I like to wake up:  Very Early   When I have to  
When I wake Up I like:  To be quiet   To talk   To listen to music  
I go to bed at:
When I go out with my friends we like to:

I tidy up my own bedroom:  Yes   No   Someone does it for me  
My attitude towards school is:  I like a lot   It is ok   I do not really like it  
I usually do my homework:  right after school   after dinner   before going to bed  
What is your personality like ? (outgoing, shy, cheerful, serious, hardwordking, optimistic, independent, quiet, neat,.. etc ):

Do you play any sports ? (Baseball, Basketball, Badminton, Ballet, Biking, Dance, Fishing, Fitness, Golf, Hockey, Skating, Horseback Riding,.. etc ):

Do you play any instruments ? ( Piano, Guitar, Violin, Cello, Flute, Trumpet, Singing,.. etc ) :

What are your passtimes? ( Movies, Music, Painting, Photography, Reading, Shopping, Video Games,.. etc ) :

Letter to the host family
Please write a letter to tell us why are you applying to study in Canada:

Travel Information
Would you like us to arrange airport transportation for you?
Arrival Date:
(example: December 14, 2006)
Airport Name:
Flight Number:
Arrival Time:
(ie. 00:00 hours - Ontario Local Time)
Arriving From:
Departure Date:
(example: December 14, 2006)
Airport Name:
Flight Number:
Departure Time:
(ie. 00:00 hours - Ontario Local Time)
Departing From:
Additional Information
Would you like to purchase Medical Insurance through Hospitalité Canada?
Yes   No
If yes, we will email you a form
  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 the Hospitalité Canada Ltd. website and it's applications.

I/We understand that Hospitalité Canada Ltd. 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 Ltd. 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 homestay 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. Students should contact their own your insurance broker, travel agent, or insurance provider for more details.

I/We undertand that Hospitalité Canada Ltd. 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 Ltd. nor do I hold Hospitalité Canada Ltd. responsible for any reason.

Do you agree to the Student or Visitor Guidelines? Read Guidelines
Yes   No  
Do you and your representative accept the program disclaimer?
Yes   No  
By submitting this application you acknowledge it true and binding