Coquitlam College

Please complete the form below to submit your Coquitlam College Student Homestay Application.

1. Student Information

First Name: *

Last Name: *

Sex: *

Student Number:

Citizenship: *

Place of Birth: *

Birth Month: *

Birth Date: *

Birth Year: *

Address: *

City: *

Province/State: *

Country: *

Postal/Zip code:

Phone: *

Fax:

Cell Phone: *

Email Address: *

Local Contact Name if Applicable:

Local Contact Phone if Applicable:

2. Parent / Guardian Information

I am: *

Parent / Guardian First Name if Applicable:

Last Name: *

Parent / Guardian Birth Month: *

Birth Date: *

Birth Year: *

Parent / Guardian Address If Applicable:

Parent / Guardian City If Applicable:

Parent/Guardian Province/State If Applicable:

Parent / Guardian Country If Applicable:

Parent/Guardian Postal/Zip Code:

Parent / Guardian Phone If Applicable:

Parent / Guardian Email Address If Applicable:

3. Accommodations & Flight Information

Accommodation Required From:

Accommodation Required To:

Do you need Airport Pickup?

Arrival Information

If your arrival time is not known, please contact Coquitlam College Homestay Department at least 10 days prior to your arrival.

4. Medical Insurance

Do you have Medical Insurance? *

Allergies

Medications presently being taken

Physical Disabilities

Special Diet?

Hobbies & Interests
Tennis
Reading
Swimming
Photography
Weight Lifting
Basketball
Bike Riding
Skiing
Track & Field

5. English Proficiency

Years of English Study *

Written English Ability *

Spoken English Ability *

6. Complete & Submit Application

Do you cook? *

Do you smoke? *

What are you looking for in a Homestay?

Do you want to live with another Homestay Student? *

Payment Method *

By clicking Submit Application, you indicate that you have read and agree to the Coquitlam College Homestay Terms & Conditions.