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 Langauge 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:

Do you have a special diet? *

Please describe diet:

Are you comfortable in a pet friendly home? *

If not please explain:

Do you observe any religious traditions in your home that you wish to disclose? *

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? *

Please provide your culinary likes and dislikes; also list any food allergies in this section as well:

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

Do you have any accessibility or mobility issues you are comfortable disclosing? *

If yes, please describe below: *

Do you have any medical issues issues you are comfortable disclosing? *

If yes, please describe below: *

I am applying for homestay in: *

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)	$300.00	$300.00
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	$800.00/month	$575/month

I understand and agree to the Payment, Schedule, Refund Policy and Terms of the Lakehead University Homestay International Program.