Rotary Adventure in Citizenship Program 2019
April 28 - May 1, 2019

Students Arrival Date: Saturday, April 27th

Please complete the form below and include all requested information.



  YES, we will billet students in our home.
Mr. / Mrs. / Ms.
First Name: Last Name:
Spouse First Name: Spouse Last Name:
Address 1:
Province: Postal Code:
Telephone (home):  
Telephone (office): for (First Name)
Telephone (cellular): for (First Name)
Are you a bilingual (English/French) household?

Yes or No

Many of the students have allergies to smoke or animals. Please indicate if you have pets (i.e. cat or dog) or if your home is not smoke-free.

Pets:Yes or No         Details:

Our participants stay in groups of two minimum, same sex. Please indicate what gender you would prefer.

Girls or Boys or Either

How many participants can you host (minimum of two)
Preferred time of arrival of your participants  ( No Preference)
Because of transportation difficulties a few students will require a Friday evening arrival or a Thursday morning departure.
Could you billet Friday evening?

Yes or No

Could you billet Wednesday night?

Yes or No

Any additional comments you think would be beneficial for us to know? If so, please leave us a note here.

The Rotary Adventure in Citizenship Program is committed to creating and maintaining the safest possible environment for all participants in our program. To this end, we have been mandated by Rotary District policy to ask for the following personal information.

PERSONAL REFERENCES; If you are new to billeting for this program, or have not billeted for the past 2 years, please complete this section.

Provide us with the name and contact information for someone who has known you for a minimum of 5 years , and who, if contacted, could attest to the trustworthiness of your household. (one or two references). If one of your contacts is a Rotarian in Ottawa please include them as your main personal reference.
Person 1


Relationship to you:
Person 2


Relationship to you:
POLICE CHECKS: Have you or your partner had a “Police Check for the Vulnerable Sector” completed within the last 5 years?

Yes or No


If yes, who and for what organization/ purpose?

If no, would you like us to send you the required documents for you to obtain this Police Check at no cost to you?
(not mandatory)



I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND my responsibilities as a host family, as described in the Billeting Overview (see below). I agree to be responsible for the safety of the students while they are in my charge.

By checking the box on the left, you agree to the above.
Do you know someone who might be interested in becoming a Host Family?
Your connection to this person:
Can we contact them using your name?

For more information, contact:

Margot Nicholls
Program Coordinator
Rotary Adventure in Citizenship Program
Phone: 613-860-1521
Fax: 613-445-6438