Contact Information
Mr.   /   Mrs.   /   Ms   /   Mr. & Mrs..
First Name:			Last Name:
Spouse First Name:			Spouse Last Name:
Address 1:
City:
Province:		Postal Code:
Telephone (home):
Telephone (office):	for (First Name)
Telephone (cellular):	for (First Name)
E-mail:
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)
Comments:
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.
Have you billeted for this program before? Yes (please proceed to Conclusion section) or No (If "no", Please complete the New Host Families section below)   New Host Families 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 Name: Address: Phone E-mail: Relationship to you:         Person 2 Name: Address: Phone E-mail: Relationship to you:
Conclusion
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 link to obtain this Vulnerable Sector Police Check? (not mandatory)        Yes
	I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND my responsibilities as a host family, as described in the Billeting Overview. Click here to download the Billeting Overview. 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?   Name: E-mail: 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
admin@rotaryottawa.com