Mr
Ms  _______________________________      ___________________________________
Family NameFirst Name

     Single Married Date of Birth / /

    Address in your country: Address in Canada (if known):
  ____________________________________      ___________________________________
  ____________________________________      ___________________________________
  ____________________________________      ___________________________________
  ____________________________________      ___________________________________
   Phone Number: _______________________       Phone Number: ______________________

Intensive ESL Program	English for Business Management
Part-Time ESL (alone)	TOEIC
Part-Time ESL (with other courses)	TOEFL
Computers	English on the Train
Academic Preparation

I would like to start: / /19 And study for:months

My visa in Canada is: student visitor Working Visa

I will need a Homestay Family: Yes No

I would like to start my homestay: / /19 End on:/ /19

I will need airport pick-up: Yes No

Airline and Flight #: Time: Date: / /19

Many Canadian families have pets. Can you live with a cat? Yes No
Can you live with a dog? Yes No

Many Canadians are non-smoking. Are you a smoker? Yes No

What family type do you prefer? No Children No preference
Teenagers Children

Do you have any allergies, special medication or health problems?

Interests and Hobbies:

Is there any food that you cannot eat?

Emergency Contact Person: Name:
Phone:

Signature_____________________________________ Date_________________________

* Please Note: Registration is on a 'first come first served' basis and should be received three weeks before the selected session begins.

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