Address:

Arrival Flight #s:

Departure Flight #'s:

Date of Arrival:

Date of Departure:

Flight Times (Arrival):

Flight Times (Departure):

Telephone Number:

Email Address:

Home Address:

Country:

Airport service required: Yes____ No ____

Length of stay: 1 month ____ 3 months ____ other ____

Name of School you will be attending in Calgary:

Name of Health Care Insurer:

List your interests and hobbies:

Do you like pets: Yes ___ No___ Maybe___

Are you a smoker? Yes ___ No ___

Do you have any food allergies or require a special diet?

No ____ Yes____ (please list)

Do you like children: Yes ____ No ____

How strong is your English: weak ___ good ___ excellent ___

Have you ever been charged with an offence?  If so, what was it?

Will you require any type of medication for illness during your stay?  If so, what kind?

Do you agree to follow and respect all host family house rules while in their home?   Yes ____  No ____