Please provide us with the following  information:

Note: We at Surrey Homestay House are committed to dealing with as many nationalities as possible. However, because we are based in Canada we can only correspond in English and are sorry for any inconvenience this may cause you, 

First Name
Last Name
Street Address
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

Age
Sex	Male Female

Nationality

Do you smoke ?  Yes No      (If yes outside only)

Do you have any diet restrictions? Yes No

If yes, please explain?

Do you have allergies ?  Yes No

If yes, what?                

What is your purpose here?        School Visit Work Other

What school are you attending? 

Street address of school?          

Do you have medical insurance?  No Yes  

Do you need airport pickup?      Yes No     

How long do you need a Homestay for?

Start Date    

End Date     

Tell us about yourself?

Do you have any questions to ask us ?

Person to contact - In case of Emergency:

Name
Work Phone
Home Phone
E-mail

Please answer all the questions as best you can or we will not reply to your request.... Be patient and we will get back to you within 24 hours.

I have read the Terms of use and Privacy policies of Surrey Homestay House and I agree to abide by these terms upon acceptance of this application.