Telephone (780) 328 6479; Fax 1 866 844 9062 Email eps@canadahomestayinternational.com Website: canadahomestayinternational.com Please check one of the following: I require homestay and custodianship arrangements I require homestay arrangements only. STUDENT PERSONAL INFORMATION SURNAME (FAMILY NAME) GIVEN NAMES ENGLISH NAME (if applicable) Male Female DATE OF BIRTH (Month Day Year ) NATIONALITY LANGUAGE ENGLISH SPEAKING ABILITY beginner low intermediate intermediate advanced fluent PERMANENT MAILING ADDRESS STUDENT S EMAIL PARENT S EMAIL TELEPHONE TELEPHONE AGENT INFORMATION AGENCY NAME: CONTACT: EMAIL: TELEPHONE #: FAX: PERIOD OF HOMESTAY REQUIRED (INDICATE DAY/MONTH/YEAR) HOMESTAY TO BEGIN: HOMESTAY TO END: HOMESTAY PREFERENCES DO YOU LIKE PETS? Yes No I am allergic DIETARY CONSIDERATIONS Regular Vegetarian Other (please explain): If no or allergic, please explain: PLEASE INDICATE PREFERENCES FOR YOUR HOMESTAY (choices are not guaranteed): Young children Teenagers No young children Another student No strong preferences PLEASE CHECK () THE FOODS THAT YOU LIKE TO EAT: Pork Chicken Rice Salads Fast Food No Pork Fish Potatoes Fruit YES OK NO Noodles/Pasta Beef WHAT ARE THE FOODS THAT YOU CANNOT EAT, OR ARE ALLERGIC TO? (If No, please tell us why) Barbeque Vegetables Asian Food Cereals STUDENT PROFILE PLEASE CHECK () THE WORDS THAT BEST DESCRIBE YOUR NATURE outgoing shy cheerful quiet hardworking neat optimistic independent studious serious Other: International Student 2011 CHI/Canada Homestay International 10.3
DO YOU REGULARLY PLAY A SPORT? IF YES, PLEASE SELECT ALL THE SPORTS YOU PLAY: Baseball Badminton Ballet Basketball Biking Dance Fishing Fitness Golf Hockey Skating Horseback Riding Martial Arts Skiing Snowboarding Soccer Swimming Tennis DO YOU REGULARLY PLAY A MUSICAL INSTRUMENT? IF YES, PLEASE SELECT ALL THE INSTRUMENTS THAT YOU PLAY: Piano Cello Flute Guitar Trumpet Drums PLEASE CHECK () THE ACTIVITIES WHICH INTEREST YOU Baseball Camping Fishing Basketball Computers Fitness Biking Concerts Gardening Board Games Cooking Golf Boating Dance Hiking/walking PERSONAL HABITS: Violin Saxophone Hockey/Skating Horse Riding Martial Arts Movies Music Singing Other: Paint/Draw Photography Reading Shopping Skiing/ Snowboarding 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. On school nights I usually go to bed at am/pm. My curfew on school nights is am/pm or I don t have a curfew on weeknights. My curfew on weekends is: am/pm or I don t have a curfew on weekends. When I go out with my friends, we like to: I tidy up my own bedroom and make my own bed yes no, my does it for me. My attitude towards school is: I like it a lot it s OK I don t really like it. I usually do my homework: right after school after dinner before going to bed. Soccer Swimming Tennis Theatre Video Games/ Computer Games MEDICAL INFORMATION Have you ever received a medical diagnosis of a physical or mental condition, and been prescribed medication for it? If yes, please provide information on the condition, the trade name of the medication and the dosage. Do you have a perceived or documented learning disability, physical handicap, social integration difficulty, behavioural concern, or history of criminal behaviour or sexual impropriety? If yes, please describe. If you are taking any medications, you must notify us in advance. Are you taking any medication? Yes No If Yes, please list trade names and dosages. Do you have any allergies? Yes No If Yes, please explain. If you regularly experience sleep disorders such as insomnia, sleepwalking, nightmares or bedwetting, please specify. Are you taking any medication? Yes No If Yes, please list trade names and dosages. Do you smoke? Yes No If Yes, you must agree not to smoke inside your school and your Homestay Host s home (you may be allowed to smoke outside). Do you agree not to smoke inside (including your bedroom)? Yes No Will you accept Placement in a home where there are smokers? Yes No YOUR FAMILY MEMBERS NAME RELATIONSHIP AGE OCCUPATION International Student 2011 CHI/Canada Homestay International 10.3
OTHER CONTACT (ENGLISH SPEAKING) IF DIFFERENT FROM AGENT NAME: RELATIONSHIP TO STUDENT: EMAIL: TELEPHONE #: FAX: STUDENT PARTICPATION AGREEMENT (PA), including DECLARATION and DISCLAIMER CHI reserves the right to accept or reject the International Student of the Student named herein, in its absolute discretion and without recourse. To be accepted by CHI, the Student named herein (and if the Student is a minor, the Student s parents or Guardians and Custodian named herein) hereby agree to the terms and conditions of the following Participation Agreement (PA): The Student is a minor if they are: under the age of 19 in the provinces of British Columbia & New Brunswick under the age of 18 in the provinces of Alberta, Ontario, & Quebec 1. Insofar as Canadian laws are concerned, the Student hereby agrees: (i) to obey the laws of Canada; (ii) not to use drugs or medication, unless prescribed by a registered physician and labeled in English; and (iii) if the Student is a minor, not to purchase or consume tobacco or alcoholic beverages, or drive a motor vehicle. 2. Insofar as the Student s relationship with the homestay Host(s) selected for the Student by CHI, the Student hereby agrees to behave as a considerate and respectful member of the homestay Host family and household. More specifically, the Student herby agrees to: (i) accept any homestay Host assigned to the Student by CHI, regardless of the homestay Host s sex, race, colour, creed, religious or cultural background (according to the Canadian Charter of Rights and Freedoms); (ii) use their best efforts to talk with and be part of the homestay Host household and participate in their activities; (iii) help their Host around their homestay home - accept responsibility for reasonable jobs (like helping with the dishes after meals); keeping their room clean; and doing their personal laundry; (iv) observe the homestay Host s behavioural rules (if any), especially concerning the use of computers and online activity; the operation of any household appliances (such as the stove or barbeque, to limit the risk of fire); curfews if the Student is going out alone or with friends, the Student agrees to tell their homestay Host where they are going and when they will be home (in case of an emergency), and to telephone their homestay Host before dinner, if they will not be home for dinner and if they likely to be return to their homestay Host late at night. (v) keep themselves clean, by regular personal hygiene; (vi) pay for any and all damage to their Host s property, caused by the Student (if any); and (vii) pay for their personal expenses, such as international telephone calls. 3. Insofar as their performance at school is concerned, the Student will: (i) attend school daily, or as otherwise instructed by the school; (ii) complete all homework and assignments; (iii) maintain at least a C grade (65%) on all tests; (iv) share the contents of any academic progress reports with their homestay Host. 4. In addition, the Student declares that: (i) the information given in this International Student is complete and correct to the best of the Student s knowledge; incorrect or incomplete information represents a breach of this Agreement and is subject to the terms of paragraph 5 herein; (ii) the Student has read and fully accepts all CHI Invoice and Payment Policy terms and conditions, including cancellation charges; (iii) the Student has read and agrees to comply with the CHI Homestay Guide for International Students; (iv) the Student agrees to pay for any and all expenses incurred by the Student or on the Student s behalf by CHI or the homestay host assigned to the Student by CHI (including but not limited to any losses or damages International Student 2011 CHI/Canada Homestay International 10.3
(v) (vi) caused by the Student, the Student s long distance telephone expenses and any medical expenses); the Student hereby waives, releases and absolves and agrees to indemnify and save harmless CHI and its officers, Directors, employees, agents and independent service providers (including but not limited to the homestay hosts and transportation service providers selected for the Student) from any and all liability for all the Student s losses and damages (including, but not limited to the loss or theft of the Student s money and the damage, loss or theft of the Student s personal belongings), personal injuries, or death, however caused; and the Student agrees to obtain any and all medical and travel insurance (including but not limited to sickness, personal injury, liability and personal belongings insurance). 5. The understanding and support of the Student helps to ensure a satisfactory homestay experience, for everyone involved. In the event of a breach of this SPA by the Student, CHI and CHN reserve the right, in their absolute discretion, to: (i) notify the Student of the breach (by fax or email or telephone) and provide the Student with twenty-four (24) hours to remedy the breach, such remedy to be subject to the agreement of CHI; and/or (ii) relocate the Student to a second and final Homestay Host, at the expense of the Student and without refund of the unused and prepaid Homestay Host fees paid to the first Homestay Host; and/or (iii) notify Citizenship and Immigration Canada of the breach (with the result that the Student s Passport may be confiscated and the Student s Study Permit or Visa may be cancelled); and/or (iv) expel the Student from the CHI International Student Homestay Program and the Student s Homestay Host, on one (1) hours written notice, to unsupervised accommodation in a hotel, at the Student s risk and expense; and/or; (v) instruct the Student to return home via the first available flight, at the Student s risk and expense; and if CHI deems it necessary, accompanying the Student to the airport accordingly. 6. The consequences of a breach of this SPA by the Student (including but not limited to the consequences described in paragraphs 5 (i) to 5 (v) herein) are without recourse to CHI, its officers and directors, employees, agents and independent service providers (including but not limited to any homestay Host and transportation service provider). The Student further agrees to reimburse CHI on demand, its fees and expenses related to any such breach (including for each relocation, Canadian $500 in fees and Canadian $100 for transportation expenses). 7. The Student also understands and agrees that this SPA forms part of their CHI and their Declaration therein. Student s Name Family Name Given Name English Name (if applicable) Signature Date Student s Parent s Names or Guardians (if applicable) Relationship (father, mother, Guardian or Custodian): Family Name Given Names Signature Date Relationship: Family Name Given Names Signature Date International Student 2011 CHI/Canada Homestay International 10.3
STUDENT LETTER In this letter to your host family, please tell us about yourself and about why you are applying to study in Canada. You may include your future goals, a little about your life at home and at school in your own country, what you are looking for in a homestay family, and any particular areas of interest you would like to learn about while in Canada. Student Photograph Student s Signature Date: International Student 2011 CHI/Canada Homestay International 10.3
PARENTAL LETTER OF INTRODUCTION Please write a letter describing your child s personality, interests, relationships, future aspirations and home life. Feel free to add any other relevant information which may be helpful to a teacher or host family. Parent s Signature Date: International Student 2011 CHI/Canada Homestay International 10.3