Phone: Fax: __________________________________
E-mail: Male Female (check one) Age:
Nationality: ___________________________
Please check the course you are registered in:
English for Academic Purposes University Bridging Program
English for Personal and Professional Communication
One Month Immersion Program
Advanced Business English
Please give the dates of the course(s) you are registered in.
Have you ever been in a homestay before? Yes No
Do you smoke? Yes No
Are you willing to stay with smokers? Yes No
Do you drink alcohol? Yes No
Do you have any allergies? Yes No
If yes, please list below:
Do you have any dietary restrictions (e.g., religious), special needs or requests? Please list them below.
Please make sure to list foods you cannot eat.
What are your interests and hobbies? Please be as complete as possible.
At home, are you a student? Yes No
If yes, what program are you studying? How many years have you been studying in this program?
If no, what is your profession?
How would you rate your English proficiency? (e.g., beginner, intermediate, or advanced)
In speaking?
In writing?
In reading?
In listening?
Have you travelled before? Yes No
If yes, where have you travelled?
Expected date of arrival in Halifax: __________________________________________________
Expected date of departure from Halifax: _____________________________________________
I will stay with my host family for a complete semester. I will pay my host family the full
semester's rent on arrival in Halifax. I agree to tell my host family 30 days before the day I
move. I understand that I may not move into my homestay until 9:00 am on the Saturday
before my first semester begins. If I arrive before that time, I will arrange my own temporary
accommodation in a hotel or hostel.
I have read and understand the terms of homestay above and agree to abide by these rules.
Signature: Date: _________________________________
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