Student Homestay Application Form

Please supply all information requested. Except for the specific, limited uses indicated in this form, all information that you supply will be kept strictly confidential.

Please be advised that only students studying in Lakehead University's English Language Program are eligible to participate in the Homestay Program.

Student Information

Have you ever been an international student before? *

Please give detail:

Student Number *

Sur / Family Name *

Given / First Name *

Age *

Gender *

Marital Status *

E-Mail Address *

Arrival Date (If Available)

Day

Month

Year

Student Questionaire

Do you have any allergies? *

Please describe allergies:

Is there a specific food plan you follow? For example, are you vegetarian or vegan? Do you not eat pork or beef? *

Please describe diet:

Are you comfortable in a pet friendly home? *

If not please explain:

Do you follow any specific religious practices at home that you'd like to share? *

Religious traditions:

Would you be comfortable living in a home that observed religious traditions? *

Would you prefer: *

Why are you interested in taking part in the Homestay program? What do you hope to learn or gain from this program? *

What foods do you enjoy and dislike? Additionally, please mention any food allergies you have.

How long are you planning to study at Lakehead University, English Language Centre? *

Do you have any challenges with movement or getting around that you are okay with telling us? *

If yes, please describe below: *

Do you have health concerns you are comfortable telling us? *

If yes, please describe below: *

Comments/Additional Information

Please Read: *

By clicking this checkbox:

I declare that all the information provided on this application is accurate and understand that any inaccurate information may invalidate this application.

	Homestay with Meal	Homestay without Meals
Placement Fee (non-refundable)	$400.00	$400.00
Refundable Damage Deposit*In the event of damages $400.00 will be charged to your Lakehead University Account upon inspection and review	$400.00	$400.00
Homestay Fees	$900.00/month	$675/month

I understand and agree to the Payment, Schedule, Refund Policy and Terms of the English Language Centre Homestay Program.