Contact Information (all fields are required to process application)

Family Name:

First Name:

English Name Used:

Student's Home Street Address:

City:

Country:

Postal Code/Zip Code :

Student's Home Telephone Number (with area or country code):

Fax Number (with area or country code):

Student Number:

Email:

Student's Email (if different from above):

Personal Information:

Male Female

Date of Birth -
Year: Month: January February March April May June July August September October November December Day:

Single Married Spouse name

Will spouse accompany you :

Which Languages Do You Speak?

If you have lived or traveled outside of your country before, please
describe where and for how long:

Do you live with your parents with another person alone ? Do you live in an apartment in a house in a condominium ?

List the names and ages of your brothers and sisters:
Name:
Age: less than 10 11 - 19 20 - 25 26 - 30 31 - 40 41 - 50 over 50 Gender: male female

Name:
Age: less than 10 11 - 19 20 - 25 26 - 30 31 - 40 41 - 50 over 50 Gender: male female

Name:
Age: less than 10 11 - 19 20 - 25 26 - 30 31 - 40 41 - 50 over 50 Gender: male female

Please specify any allergies (eg. Food, pet animals, medication, etc.) that
may affect your Homestay:

Please describe any other medical and physical conditions which
may affect your Homestay:

Please indicate your level of English proficiency:

Lifestyle

Please describe your hobbies and leisure activities. Please include as much detail as possible inorder to make the best possible match.:

Do you like outdoor activities? very much a little not at all
Which ones do you like?

Do you like sports? very much a little not at all
Which ones do you like?

Do you like the arts? very much a little not at all
Which ones do you like?

Do you play a musical instrument? yes no
If "yes" which one(s)?

Do you enjoy cooking? yes no

If "yes" what do you like to cook?

Indicate the adjectives that best describe you:

Are you a
Non-Smoker
Smoker
Would you accept a Homestay where you can only smoke outside? Yes No
Will you share a home with someone who smokes? yes no

Would you like to live in a home with children? Yes No Maybe
If 'No' or 'Maybe', please describe your concerns:

Would you like to live in a home with pets? Yes No Maybe
If 'No' or 'Maybe', please describe your concerns:

Please tell us anything else about you that will help in placing you with a suitable family.

Describe your lifestyle. (ex: your personality, interests, and what you enjoy doing in your free time).

What are your hopes for your Homestay experience?

Dietary Requirements

Please describe the foods you are accustomed to eating:
Meat:
Never Sometimes Everyday
Vegetables:
Never Sometimes Everyday
Rice:
Never Sometimes Everyday
Pasta:
Never Sometimes Everyday
Fish:
Never Sometimes Everyday
Fruit:
Never Sometimes Everyday

Please describe any dietary restrictions:

Are you?
Vegetarian Vegan No pork diet (pig meat)

Comments Please describe any other concerns or questions which you have:

Study Program

Term

Fall (September)
Winter (January)
Spring/Summer (May)

Visa Status

Travel Information - NOTE: YOU MAY NOT MOVE IN TO HOMESTAY UNTIL JANUARY 1, 2013.

1. Departure From Home

Date: Airline:

Time: Flight #:

2. Arriving in Winnipeg

Date: Airline:

Time: Flight #:

Port of Entry to Canada Toronto Vancouver
Other:

I understand that I will not be given a Homestay placement until I have provided my arrival information and paid $2,850.00 CAD ($2,900 for ICM students). These fees icludes a non-refundable, $150.00 application fee or $200.00 application fee for ICM students, a $100 administrative fee and $2,600.00 for the first 4 month's Homestay). *Fees are subject to change without notice.

I have:

Please CONTACT ME with any questions you might have.

Ann Friesen
Homestay Coordinator
University of Manitoba, English Language Centre
Enrolment Services
520 University Centre, Winnipeg, MB R3T 2N2
Tel: 204-474-6809
FAX: 204-275-8098
Emergencies Only: Tel: 204-228-2280
Email: homestay@umanitoba.ca