Contact Canada

Language School & Homestay/Farmstay Application Form.

Please read CCES homestay agreement & waiver form before you fill in the form below.
After you filled out the form, please submit it by hitting "SUBMIT" button. Caution:First section of the form is for all applicants and the last half is for homestay, farmstay & language school form accordingly.

Language School & Homestay/Farmstay Application Form
*Mandatory
This section is for all applicants
*Preferred area
'Western Canada' includes YUKON & NWT
*NameFirst:Last:
Example: Bob Smith
*Postal Code
*Address
*TelHomeWorkCell   - -
Fax: HomeWork   - -
*E-mail Address
Credit Card Info
This is guarantee purpose only to start our arrangement for you. You can choose your method of payment after we complete the arrangement.
Type
Card Number: Eg4500 0123 4567 8900

Card Holder EgTARO YAMADA

Valid Until Eg05/03
SexFemale  Male
Date of Birthyr: mo: dy:    Age:
English LevelBeginnerLow intermediateIntermediate
Hi intermediateAdvanced
English Proficiency TestType:   Score (Level):
Type of Visa

Expiry Date:
Your current job/school name
Hobby
Emergency Contact.
If it's defferent from above.

Tel: - -
Arrival Date/Time in Canada
If you have any connecting flight, please let us know
Arrival Date:
yr: mo: dy:
Arrival Time:
Flight #:
Passport #:
International Driver's licenseYES, I have.NO, I don't.
Smoker?YESNO
Dislike Food
Health Problem?
Allergies?
Travel/Health InsuranceNOYES  Insurance company:
Language School Application Form    Farmstay Application Form
Form below is for homestay applicant
Language School Name during homestayName:
Duration:
Start: yr: mo: dy:
from
End: yr: mo: dy:
Preferred Homestay Area
Preferred Homestay Family StructureFamily with small childrenFamily with teenager
Family without childrenNo preference
Homestay Duration:Duration: month
Start Date:
yr: mo: dy:
End Date:
yr: mo: dy:
PetDog OKCat OKDog NOCat NONo preference
What is your first priority:Distance to school/DowntownFamily Structure
No Preference
Other:
Do you have any homestay experience?NOYES  LOCATION:
Any message to homestay host?
Language School Application Form    Homestay Application Form
Form below is for farmstay applicant
Farmstay DurationStart Date:
yr: mo: dy:
End Date:
yr: mo: dy:
Farmstay Preference(Farm Type)
Preferred Farmstay Location
Preferred Family StructureFamily with small children Family with teenager
Family without childrenNo Preference
PetCat: OKSMALL CAT OKOUTSIDE OKNO CAT
Dog: OKSMALL DOG OKOUTSIDE OKNO DOG
Other pet: OKNOT OK
What do you want to help out on the farm? (1=highest level of interest & 5=lowest)Animal help(feeding, watering, cleaning barn etc)
Ranch help(haying, fences, yard work etc)
Field work(weeding, harvesting vegetables & fruits etc)
House chores(cooking, cleaning, vacuuming etc)
Child care
What do you want to try/learn the most during your stay?
Why do you want to live on a farm? (1=most & 5=least)Learn about agriculture in Canada
Experience life in the Canadian countryside
Practice English and learn more about the culture
Make Canadian Friends
Other
Homestay Application Form    Farmstay Application Form
Form below is for language school applicant
Preferred Location(City)
Preferred school typeLanguage SchoolVocational School
College/University ESL
College/UniversityPrivate high school
Public high school
Preferred school name
Start Date:yr: mo: dy:
Duration
Preferred course: Full day class (24hrs/week)half-day class (15hrs/week)

Preferred course name:
Homestay/CustodianshipHomestay Placement: Contact Canada Homestay
School HomestayNot needed

Custodianship: Contact CanadaNot needed
Applicant under the age of 18 must arrange to have custodianship when applying for student visa. Contact Canada host family can be arranged to be a custodian.
Please fill in the form if needed before submitting the form.
Please make sure to check mark agreement section before sending the form.
Optional Optional Airport Pickup ($90 + 7% GST)
YESNO
Do you require orientation? ($30 + 7% GST)
(Available in Vancouver or Toronto)
YES NO
AgencyAgent Name:
Contact Person:
*SurveyHow did you hear about Contact Canada?
FriendAdvertisementInternetAgency
Message to Contact Canada
*I agree to all conditions stated on the agreement & waiver form
AgreeDisagree
     


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