CAMPBELL RIVER HOMESTAY APPLICATION Page 1

If you wish a Homestay, please complete this form and mail or fax it to:

Cross World Canada
192 Rockland Rd., Campbell River, British Columbia
V9W 1N6, Canada / Passport Photo
Name: (Last, First, Middle)
Permanent Home Address:
City: / Country: / Postal Code:
Email Address: / Telephone: / Fax:
Male □ Female □ / Age: / Date of Birth:
year / month / day
Passport Number: / VISA: □ Study Permit □ Visitor Visa
□ Working Holiday
Medical Insurance Company Name: / Medical Insurance # / Expiry Date of Medical Insurance:
Emergency Contact Person: Mr./ Ms. / Relationship of Contact: / Telephone:
Fax:
If you are working through an agent, please provide the agent’s name and email address: / Agent’s Company Name:
Agent’s Name: / Agent’s Email:
Approximate Date of Arrival:
Length of homestay:
From: / To:
Signature of Applicant
Date:
Personal Information / Page 2
I am:
Additional Comments: / □ Shy / □ Adapt Easily / □ Independent
My English level is: / □ Advanced / □ Intermediate / □ Beginner
My state of health is: / □ Very Good / □ Good / □ Fair / □ Poor
I have illnesses: / □ No / □ Yes
Specify:
I have allergies: / □ No / □ Yes
Specify:
I take medication: / □ No / □ Yes
Specify:
Food exemptions: / □ No / □ Yes
Specify:
Vegetarian: / □ No / □ Yes
Specify:
Have you ever visited another country? / □ No / □ Yes
Which countries?
Do you smoke? / □ No / □ Yes
Do you like pets? / □ No / □ Yes
Do you like children? / □ No / □ Yes
Your family members at home:
Name / Age / Male/female / Occupation/school
Page 3
My Family: Circle the words that best describe your family, and underline the words that least describe it.
warm strict formal informal orderly reserved conservative
serious demanding happy active united indifferent tolerant
protective open political disciplined religious flexible intellectual
My Interests: please number, in order of preference, up to 10 activities that you enjoy:
__ reading __ surfing __ skiing __ listening to music
__ arts/crafts __ water skiing __ painting/drawing __ camping
__ theatre __ attending concerts __ volleyball __ martial arts
__ movies __ wrestling __ ballet __ visiting museums
__ drama __ modern dancing __ fishing __ playing individual sports
__ golf __ snowboarding __ watching sports __ soccer
__ cooking __ chess __ hiking __ gymnastics
__ playing cards __ basketball __ bicycling __ tennis
__ table tennis __ rugby __ American football __ hiking, backpacking
__ baseball __ photography __ sailing/boating
__ participating in social clubs/school clubs/political clubs/religious groups
__ collecting (name one or two)______
__ singing in an organized group
__ playing an instrument (which instrument?) ______
__ other______
Homestay Preferences (please circle)
Would you prefer a family with:
Young children? YES NO
Teenagers? YES NO
Another International Student? YES NO
A dog? YES NO
A cat? YES NO
What other information would you like us to know about you?
Please complete page 4
Please list two references (non-relative) that we may contact with regard to your suitability as a student homestay / Page 4
REFERENCE 1 / REFERENCE2
NAME / NAME
ADDRESS / ADDRESS
POSTAL CODE / POSTAL CODE
TELEPHONE / TELEPHONE
OCCUPATION / OCCUPATION
RELATIONSHIP / RELATIONSHIP
.
SIGNATURE
SIGNATURE OF YOUR PARENT
DATE

Thank you very much