3248 Rue Des Quatres-Saisons, St-Hubert, QC, J3Y 8P2, Canada
Tel: (450) 462-7870
Fax: (450) 550-1659
Email: info@minervahomestay.com

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Last name(s) :

Address :

City:

Postal code:

Telephone:
Home:

Cell:

Work:


Fax number:

E-mail address:


HOST PARENT(S)

First name:
Male
Female

Occupation:

Interests:

Age:

Level of education:

Specialized diplomas:

Country of birth:

Mother tongue:

Other languages:

Religion:


First name:
Male
Female

Occupation:

Interests:

Age:

Level of education:

Specialized diplomas:

Country of birth:

Mother tongue:

Other languages:

Religion:


CHILDREN

First Name:
Male
Female

Interests:

Age:


First Name:
Male
Female

Interests:

Age:


First Name:
Male
Female

Interests:

Age:


First Name:
Male
Female

Interests:

Age:


ACCOMMODATION

I am interested in offering:

Homestay
Rent-a-room

What kind of accommodation can you offer?

House
Duplex
Apartment
Other

How many rooms do you have available?

One
Two
Three
More

Do you smoke?

Yes
No

Do you have any animals?

Yes, please specify:

No

Do you have any physical handicaps?

Yes, please specify:

No

Do you own a computer?

Yes
No

Wireless internet connection?

Yes
No

Language spoken in the home:


Does your family have any special interests?


How would you travel to downtown:

Travel time in minutes:

Why do you want to take a foreign student in your home?


How did you hear about Minerva Homestay?

Advertisement, in which paper?
Internet
Friend, name of friend:

I have read Minerva's webpage "Become a host":
Yes
No


If I/we are accepted as Minerva host(s), we agree to provide Minerva with a Good Conduct Certificate for the adult members of our family.
Yes
No




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