application

                         Language Achievement Canada
                              Homestay, Summer Camp & ESL
                                         Application Form

Name:
Address:
Telephone:               Fax:

Course Information
Start Date: Day:     Month:       Year:
Age:      Male:          Female:
Any current English ability: Yes:    NO:
Basic:     Intermediate:    Advanced:
Length of stay: From:            to:
Travel Information
Date:             Time:
Airline:                               Flight Number:
Do you wish to be met at airport? Yes:        No:

Accommodation
Do you require accommodation? Yes:         No:
If yes, please answer the following:
Private room:          Shared Room:
If shared room , name of preferred room mate:
Do you mind pets in the house? Yes:          No:
Do you have to follow any special diet? If yes,
specify:
Do you have any medical problems or allergies? Yes:      No:
If yes, specify:
Do you prefer a smoke free home? Yes:         No:
What kind of hobbies or activities do you like?

Signature of applicant:

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