Enter Your Name, Email, Phone Number, Gender and Age
Your First & Last Name:
Your email address:
Phone:
Gender: Male     Female
Age:
Date Of Birth:    (mm/dd/yyyy)
Custodian Required: Yes     No     ( A Custodian or Guardian is required if you are under the age of ( 18 )
Student ID Number:
I will be Attending: High School   English Classes   Collage   University   Looking for Work  
Doing Research Work
Do you Smoke: Yes     No
English Level: Beginner     Intermediate     Advanced
How did you hear about
The DEWBERRY HOMESTAY:
Enter Your Perminent Home Address (Where you were born)
Address:
City:
   Province/State:
Postal Code/Zip:     Country:
Booking Information
    What date(s) are you requesting your Homestay?

Homestay Start: The Date you will arrive at the Homestay.

Month:
Day:
Year:
Homestay End: The Date you will check-out of the Homestay (We must have this date.)
If you do not Provide your Check Out Date you will be book for 31 days Only.

Month:
Day:
Year:
I Have Student Visa: Yes     No
I Have Work Visa: Yes     No
I Have PR Visa: (Permanent Resident)
Yes     No
I Have Health Insurnace: Yes     No
Please Select a Room:
My Time of Arrival: ==>   If we are not picking you up at the Airport, please let us know your expected time of arrival at the Homestay
Airport Service 
    If you would like us to pick you up at the Airport, Please provide the following information.   Airport Pick-Up or Drop Off Fee is $75.00

Airport Pick-Up: Yes     No
Name of Airline:
Flight Number:
Arrival Time:   at Edmonton Alberta Internation Airport
Arrival Date: Month:
Day:
Year:
Emergency Contact Information: 
Contact Name:
Relationship to you:
Language Spoken:
email address:
Phone:
Address:
City:
   Province/State:
Postal Code/Zip:     Country:
Have you any food allergies or dietary needs? 


Do you require special meals?
No

Halal (Some limitations may apply)

Vegetarian (Some limitations may apply)
Enter Additional Comments:





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