EAP Language Assessment Fee Paid on. a `EAP+Degree student an `Open Studies Student for `EAP Only. Female Male Date of Birth: Year Month Day Address:

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1 University of Calgary Faculty of Education English for Academic Purposes Program (EAP Program) Homestay Scheme for EAP Program Students Student Application Form Please download and print this application form. Write clearly, in English, using a ballpoint pen. If your writing is difficult to read, your application may be delayed. Please send it either by mail to: Mr. Ming Lee Homestay Coordinator English for Academic Purposes Program (EAP Program) Faculty of Education, University of Calgary EDC170 Education Block 2500 University Drive rthwest Calgary, Alberta, Canada, T2N 1N4 Or by fax to: Mr. Ming Lee at Or by to Mr. Ming Lee : mlee@ucalgary.ca 1. Applicant Family (Last) Name UCID # I am admitted to the U of C as: Given (First) Name EAP Language Assessment Fee Paid on a `EAP+Degree student an `Open Studies Student for `EAP Only Female Male Date of Birth: Year Month Day Address: (Apartment / Room Number) (Apartment Name) (Street Number) (Street Name) (City) (Province / County / State) (Country) (Postal / Zip Code) Tel: Fax: Address: (Applicant must provide this information for communication purpose and so please print it clearly) First Language: Other Language(s) Spoken: Expected Date of Arrival in Calgary: Year Month Day Page 1 of 6

2 2. Emergency Contact Person Contact person in your country of origin (parent / family member / guardian) Family (Last) Name Given (First) Name Relationship to You Address: (only if different from the address on page 1) _ (Apartment / Room Number) (Apartment Name) _ (Street Number) (Street Name) _ (City) (Province / County / State) _ (Country) (Postal / Zip Code) Home Phone Numbers: Tel: Fax: Work Phone Numbers: Tel: Fax: 3. Applicant s Personal Information & Preferences 3.1 How would you rate your oral English? Poor Fair Fluent 3.2 What type of host family do you prefer? A single parent/person A couple with no children at home A couple with baby or pre-school children A couple with children ages 5 12 A couple with children 13 older Any type of family is fine 3.3 Many Canadian families have pets. What would you prefer? A family with several pets A family with cats only A family with dogs only A family with no pets Preference 3.4 Do you smoke? Yes (If you smoke, you will not be allowed to smoke inside the house of your host family unless you are given permission by your host family parents.) Page 2 of 6

3 3.5 Would you prefer to live with a non-smoking family? Yes Does not matter 3.6 Do you drink alcohol? Never/Seldom Sometimes Often (If you drink alcohol, you will not be allowed to drink inside the house of your host family, especially when in front of children, unless you are given permission by your host family parents.) 3.7 Are you currently on any medication or do you have any health problem(s) that your host family should be aware of? If you do not provide this information, you may endanger your health and your homestay will be cancelled immediately. Yes (If yes, please describe in details): 3.8 Do you have any allergies? Yes (If yes, please describe in detail): 3.9 Is there any type of food that you cannot eat due to religious or dietary reasons? Yes (If yes, please describe in detail): 3.10 Are there any types of food that you do not like? Yes (If yes, please describe in detail): 3.11 Would you live with a family hosting another international student(s)? (Each international student has his/her private bedroom.) Yes Page 3 of 6

4 3.12 Brief introduction of yourself to your host family. Write about yourself in English. You may add more page(s) if needed. Describe: Your personality, hobbies and interests, studies; Your family and hometown; Your study goals at the University and for a career. 4. Agreement & Medical Authorization I,, am an applicant for the Homestay Scheme, offered through the English for Academic Purposes program (EAP Program) in the Faculty of Education at the University of Calgary. 4.1 Agreement I understand that the amount of the monthly homestay fee and the security/damage deposit were solely set by the host family. I understand that I must follow the rules of the Homestay Scheme listed in this `Student Application Form and any instructions given to me by my host family and the Homestay Coordinator. If I do not follow these rules and instructions, I will be asked to leave this Homestay Scheme immediately. My participation in the Homestay Scheme may be terminated at the sole discretion of the University of Calgary. In addition, I specifically agree: To participate in the Homestay Scheme for a minimum of one term (4 months); Thereafter, to notify my host family and the Homestay Coordinator at least 30 days before I leave the Host Family; To pay the monthly `Homestay Fee to my host family in advance for the following month; To pay all telephone bills charged by me to my host family. Upon arrival at Calgary, I will pay the following fees in Canadian dollars to my host family: $50.00 airport pick-up fee if such service was required by me. One month homestay fee; A security/damage deposit if required by my host family; (This is usually the same as one month s homestay Fee) I agree that the laws in force in the Province of Alberta shall govern this agreement and the Alberta Court of Queen s Bench shall have exclusive jurisdiction to determine any dispute over the terms of this agreement. Page 4 of 6

5 4.2 Releases from Liability I understand that there are risks associated with travel and living in a foreign country in addition to the normal risks of daily life. I understand that I should obtain insurance to ensure coverage against loss or damage to my property. I understand that it is my responsibility to obtain a private medical insurance to protect me if my `Study Permit allows me to study in the University of Calgary for less than 1 year. I understand that it is my responsibility to apply for the Alberta Health Care Insurance Plan as soon as I arrive in Calgary or within 3 months of arriving in Alberta if my `Study Permit allows me to study in the University of Calgary for 1 year or more. I hereby fully release and discharge the University of Calgary, its employees, officers and Board Members, and the host family, from any and all claims, causes of action, expenses, damages and demands of any and every kind and nature whatsoever, at law or at equity or pursuant to any statue, which I may have for any injury, loss or damage to any person or property arising in any way from: (i) My participation in the Homestay Scheme; or (ii) My actions outside of the Homestay Scheme, including but not limited to, independent travel or absences from the University. I shall indemnify the University of Calgary, its employees, officers and Board Members and the host family from any and all claims, damages, financial obligations or liabilities which may be brought or made against them as a result of any loss, damage or injury to any person or property caused by my acts or omissions. 4.3 Medical Treatment If I become incapable, in the opinion of a registered medical practitioner, of consenting to medical treatment, I nominate the Homestay Coordinator or an adult member of my host family to consent to medical treatment on my behalf when the registered medical practitioner advises that such treatment is in the best interests of my health and well-being. The University of Calgary, the Homestay Coordinator, or the host family may take reasonable actions in the event of my injury, illness, or incapacity, including transporting me back to my home country at my own expense. I waive and release all claims against the University of Calgary, its employees, officers and Board Members, the Homestay Coordinator, or the host family, for any decisions or actions made relating to my incapacity, illness or injuries. 4.4 Homestay Placement Fee (n-refundable) The `Homestay Placement Fee is $ Canadian dollars. It is non-refundable and is not a partial payment of the monthly homestay fee. Do not pay this fee when submitting this application form. Applicant can pay this fee by cash, or a bank draft or a money order, in Canadian funds, payable to University of Calgary when the applicant is here in Calgary. 4.5 Homestay Rules I Must Follow I respect my host family as I am a member of my host family; I treat my host family parents as I would my parents; I learn the rules of my host family. I will ask my host parents when I am in doubt; I will not do anything that is not allowed by my host parents; Page 5 of 6

6 4.5.5 I must purchase my own long distance phone card(s) for my long distance phone calls. I must not use my host family s long distance phone service unless I am authorized to do so and in that case, I must pay all telephone bills charged by me to my host family; I check with my host parents if they expect me to come home at a specific hour; If I know I will be late, I will tell my host parents where I am, why I will be late and when I will be home; If I plan not to return home at night, I must call my host parents. Tell them where I am, how they can reach me and when I will be home; If I invite a friend to visit me at my home, I ask for permission from my host family first; & I respect cultural differences. I HAVE READ AND UNDERSTAND THE CONTENTS OF THIS AGREEMENT WITH THE UNIVERSITY OF CALGARY Applicant s Signature Date (Year / Month / Day) Parent s/guardian s Signature Date (Year / Month / Day) SIGNED IN THE PRESENCE OF EACH OTHER 5. Before you send out this `Student Application Form 5.1 Complete all sections of this application form. 5.2 Attach 2 passport-size photos with your name (Surname, Given Name) clearly printed on the back. 5.3 Make a photocopy of this application form for your record. 5.4 Send your application form to Mr. Ming Lee as indicated on top of page 1 of this form. 5.5 For any query please contact Mr. Ming Lee at: Phone: Fax: mlee@ucalgary.ca 6. Collection of Information The personal information on this form is collected under the authority of the Freedom of Information and Protection of Privacy Act. This information will only be used to coordinate your homestay placement and to contact your family in your hometown in case of emergency. It will not be used for any other purpose with the exception of the information you provided in item number 1, 2 & 3.12 which will be shared with your potential host family. February 2009 Page 6 of 6