Student Homestay Application
Contact Information
First Name
Last Name
Sex
Select
Male
Female
Birthdate
Home Address
Telephone
E-Mail
Nationality
Arrival Information
Arrival Date
Arrival Time
Flight Number
Length of stay in Canada
Name of school attending in Winnipeg
Medical Information
Do you have any medical conditions?
Select
Yes
No
If yes, please explain.
Are you under doctor care at present?
Select
Yes
No
Are you allergic to anything?
Select
Yes
No
If yes, please explain.
Personal Characteristics
Do you smoke?
Select
Yes
No
Which one best describes you?
Select
Quiet
Sociable
Outgoing
Do you spend a lot of time at home?
Select
Yes
No
Do you enjoy an active social life?
Select
Yes
No
What sports do you enjoy?
What is your favorite music?
Other hobbies:
Living Conditions
Do you want a private room?
Select
Yes
No
Would you live with a family that has children?
Select
Yes
No
Would you live with a family that has pets?
Select
Yes
No
Would you live with a family that smokes?
Select
Yes
No
Would you live with a family that
has another international student?
Select
Yes
No
Our placement policy guarantees you'll never be placed in a home with a student who speaks your first language.
English Level & Program Information
Please comment on your English level and what ESL program you have chosen (i.e. impact, access,TOEIC).
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