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Personal Information
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| 姓：Last Name |
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| 氏名：First Name |
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| 生年月日：Date of Birth |
day month year
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| 住所：Address |
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| 市町村：City |
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| 国：Country |
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| 郵便番号：Postal Code |
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| 電話番号：Phone |
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| Fax |
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| 国籍：Nationality |
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| 母国語：Native Language |
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Homestay Details
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| Do you smoke? タバコは吸いますか？ |
Yes No |
Do you prefer to stay with a family:
どのような家族のスタイルをご希望ですか |
with children without children no preference
with pet without pet no preference
smoking family non smoking family no preference
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Do you have any allergies?
アレルギーはありますか？ |
No Yes |
Are you taking any medication?
薬を飲んでいますか？ |
No Yes |
Do you have any disabilities?
何か障害はありますか？ |
No Yes |
Are there any foods you cannot eat?
食べれないものはありますか？ |
No Yes |
English Level
英語のレベル |
Beginner Intermediate Advanced |
Level of education completed
最終学歴 |
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What is your major area of study?
専攻は何ですか？ |
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| What will your visa status in Canada be during your course of study? ビザの種類は何ですか？ |
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What are your hobbies and interests?
趣味は何ですか？ |
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Homestay start date
ホームステイ開始日 |
day month year |
Do you require airport pickup?
空港出迎えが必要ですか？ |
No Yes
Flight Details:
Arrival Date
Flight Number
Arrival Time
Arrival Airport
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Do you require airport drop off?
空港見送りが必要ですか？ |
No Yes
Flight Details:
Departure Date
Flight Number
Departure Time
Departure Airport
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| You will be contacted for payment and other information upon the receipt of this form by the VIA Team. |
