E-mail address:  
Confirm e-mail
Family name: 
Given name: 
HOME COUNTRY ADDRESS

Street:        

City:
Prov/state:
Country:
Postal Code: 
Tel Number: 
Fax Number:
Date of Birth: MM/DD/YYYY 
Are you: Male   
Single 		Female
Married
How did you hear about Canadian English Center? 
PROGRAM INFORMATION
Program chosen:
When do you want to begin your studies?

Start Date: MM/DD/YYYY

End Date:  MM/DD/YYYY   
#of weeks:
Time:     
ARRIVAL INFORMATION
Please provide arrival information even if you do not require airport reception or drop off.
Airport Reception: 
  Yes No 		Airport Drop Off: 
No YES
Date:   MM/DD/YYYY    Date:   MM/DD/YYYY     
Time:     Time:
Airline & Flight #: Airline & Flight #:
HOMESTAY
Yes No:                Number of nights:       

From: To:

Preferred Host Family Characteristics:
Children   Yes No
Smoking   Yes No
Pets          Yes No
Do you have any health problems or allergies? 

Interests and Hobbies:
Message for Host Family:
Emergency Contact:
Name:
Relationship
Telephone:
Fax:

Method of Payment    

Please read the refund policy before making payment.
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