Please read the Homestay guidelines prior to submitting your application.

1. General Data - Primary contact person

Family name:

First name:

Address:

Postal Code:
Primary Email:
Alternate Email (optional):
Home Phone :

Work Phone :

Cell number :

2. Resident members in your home, including yourself, family, other students or boarders

Primary Contacts Name:
Date of Birth - Year: Month:
Day:
Occupation: Schedule: Full time Nights Part time Week-ends Days Evenings Other

Name:
Relationship to you:
Date of Birth - Year: Month:
Day:
Occupation: Schedule: Full time Nights Part time Week-ends Days Evenings Other

Name:
Relationship to you:
Date of Birth - Year: Month:
Day:
Occupation: Schedule: Full time Nights Part time Week-ends Days Evenings Other

Name:
Relationship to you:
Date of Birth - Year: Month:
Day:
Occupation: Schedule: Full time Nights Part time Week-ends Days Evenings Other

Name:
Relationship to you:
Date of Birth - Year: Month:
Day:
Occupation: Schedule: Full time Nights Part time Week-ends Days Evenings Other

3. Information about you and your family

What languages are spoken in the home?

Have you or members of your family travelled or lived outside of Canada?
If yes, to what countries and for how long?

What are the interests of the adults in the household?

In what kind of leisure activities do family members participate?

What kind of leisure activities can you offer a student?

Does anyone in the family play a musical instrument?
If yes, what instrument(s)?

What are the mainstays of your family's diet?

Please note any dietary practices or restrictions followed by your family

Do you have pets?
If yes, what kind and how many?

Are there any smokers living in your home? yes no
If yes, do they smoke inside your home?
Would you accommodate a student who smokes? yes no
Would you accept a student who was
willing to smoke outdoors only? yes no

4. Information about your house

Please describe your home (number of bedrooms, washrooms, levels)

Please describe the student's room (location in home, size, furniture, etc.)
Please note: if the student's room is located in the basement, you must provide the window's measurements.

Are there operating smoke detectors on each level of your home? yes no
Do you have a fire extinguisher installed in your home? yes no
If yes, Where is it located?
Do you have a washer and dryer? yes no
Do you have high speed internet? yes no Wireless yes no
Is there internet access in the student's room? yes no

Regarding insurance, does your property and/or
fire insurance cover a student's belongings? yes no

Does your insurance include liability for a student? no yes
How long does it take to walk from your home to the bus stop? less than 10 min 10 to 20 min more than 20 min

Please use the navigo website to answer the following questions:

All times should be based on a 8:30 am University arrival time, please include walking time in your response.

What is the Bus Route Number ?

How long a bus trip is it to the university? less than 10 min 10 to 20 min 20 to 30 min more than 30 min
How long a bus trip is it to downtown? less than 10 min 10 to 20 min 20 to 30 min 30 to 40 min more than 40 min
Will the student need to transfer buses? yes no
How many buses to the university? 1 2 3 more than 3
Do these buses run on weekends? yes no
If no, what is the alternative?

5. HOMESTAY information

Have you had a HOMESTAY student before? yes no
If yes, please indicate the HOMESTAY program, when involved, include the name and phone number of the Homestay Coordinator (U of W, U of M, IEP, high school).

Can we contact this person for a reference? yes no
Why do you want to have a student live with your family?


How did you find out about our program?

Please indicate by what date you are available to receive a student:

How many students do you wish to accommodate? 1 2 3 4
What gender? No Preference Female Male
Would you prefer a student who is independent or someone who enjoys and anticipates spending time in activities with your family?

Additional comments:

6. References

Please provide the names of three references that will be prepared to support your application.

Acceptable references are from friends, supervisors or co-workers (past or present), only. 

These references must  fill out the online Reference Form and submit it on your behalf.
For your convenience, copy and paste the text in the box below in an email to your reference.

1:
2:
3:

7. Winnipeg Police Service Criminal Record Search Certificate

We require that host families submit a Criminal Record Search Certificate (CRSC) with Vulnerable Sector (Screening) Search from the Winnipeg Police Service for each resident over the age of 18. Please note that we do not accept CRSC's from any third parties, companies or other police services. You must send the original form to our office by either mail or in person and a staff member must see an original certificate and we will keep a copy for our records. New applicant's CRSC must be no older than one (1) year from the date of application. We may ask you for an updated criminal search certificate every five years. Our office information is provided at the bottom of our Family Guidelines webpage.

You can choose to apply online or in person only through the Winnipeg Police Service. The link for applying online is:

winnipegpolice.ebackgroundcheck.ca/Contents/Apps/eBackgroundCheckService.aspx

It is important that you select, sign and date the VULNERABLE SECTOR SEARCH section of the application. CRSC's without the VULNERABLE SECTOR SEARCH will not be accepted and it will be the responsibility of the applicant to request a new CRSC from Winnipeg Police Service.

Please note that those who apply online, must pick up the CRSC in person at the Winnipeg Police Service located at 151 Princess Street. Don't forget to bring two (2) pieces of ID: a government issued photo I.D and another form of I.D. with your name on it. This is mandatory. See above link for more information.

8. Please check in support of the following: