Homestay Sign-up Form

Your registration with EMCI is not guaranteed until this application is reviewed by our Registrar's Office. If you have any difficulties in completing this form, please contact us by e-mail: info@emcicanada.com

Although at EMCI we try place you in a Homestay family according to your preferences and requests, please note that requests are not guaranteed.

Please provide accurate information for the following fields.

X Indicates response required.

Agent:
Title:		X
First Name:		X
Last Name:		X
E-mail Address:		X
Birth Date:		X (mm/dd/yyyy) (include /)

Address:
City:
State/Province:
Postal Code:
Country:		X

Phone Number:		X
Fax Number:
Emergency Contact:
Relationship:
Languages Spoken:		X
Your English Level is:

Are you a vegetarian?		X
Do you want to live with pets?		X
What kind of pets?
Are you a smoker?		X
Do you want to live with children?		X
What age (Children)?

Please list the foods you cannot eat:

Do you have any medical conditions?

Do you have any allergies?

Please list your hobbies:

Do you have any special interests?


Homestay Start Date:		X (mm/dd/yyyy) (include /)
Homestay End Date:		X (mm/dd/yyyy) (include /)

Arrival Date:		(mm/dd/yyyy) (include /)
Arrival Time:		(hh:mm:) PM or AM
Airline:
Flight Number:
Arriving From:
Visa Status:
Departure Date:		(mm/dd/yyyy) (include /)
Departure Time:		(hh:mm:) PM or AM

By clicking on sign-up you agree with the EMCI Refund Policy and Homestay Rules, and terms incorporated therein. You also agree to EMCI processing and storing your information in Canada. By clicking YES, you are attaching your electronic signature to this Homestay Application. You are aware of your rights and responsibilities between yourself and EMCI Canada.