Join Our Host Family Program

Main Applicant
*Your First Name:
*Your Family Name:
*Date of Birth:	day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
*Street and Street Number:
*City:
*Postal Code:
*Country:
Contact Details
*Home Phone:
*Work Phone:
Cell Number:
*Email Address:
Website:
Skype Address:
*Specify the number of household members living at your address:	1 2 3 4 5 6 7 8 9 10
*Please list all household members living at your address:
Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date: Name: Birth Date:
Location Details:
*Are you within walking distance of ECSL?	Yes No
*How many kilometres are you from the school?
*What is the closest intersection to your house?
*Are you on a bus route?	Yes No
If yes, what route number?
*How many minutes to downtown Halifax by bus?
Accomodation Details:
*Please provide a description of your home:
*Please provide a description of the area that you live in:
*Please provide a description of the Student bedroom:
Which of the following are available for students to use in your home?
Private Room Dresser Cable TV Private Bath TV in Room Family Room Shared Bath DVD in Room BBQ Closet Stereo in Room Pool
*Do you have internet access?	Yes No
*Do you have High Speed Internet?	Yes No
*Is there a wireless network?	Yes No
Lifestyle Information:
*Are there pets that live in your home?	Yes No
If Yes, please specify:
*Smoking outside is allowed:	Yes No
*Are there any other restrictions?
*Main language used in the household:
*Student gender preference:
*List any other preferences:
*You will provide assistance with:
*Our typical weekend activities include:
*Hobbies of Family Members:
Any other details you feel are relevant:
*Introduction letter to your student:
Security:
All successful applicants will be required to sign our Homestay contract and provide a police certificate for each resident in the home that is 18 years of age or older.
*By submitting this application, you declare that all information is true and accurate to the best of your knowledge.
*Anti-Spam Security Please enter the code displayed in the image in the box provided

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