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  • 1. American Cultural Exchange Service One Lake Bellevue Drive, Suite 200 Phone: 1-800-661-2237 or 425-453-2237 Bellevue, WA 98005 Fax: 425-453-2239 U.S.A. Email: Info@ExploreTheWorld.org Web: www.ExploreTheWorld.org U.S. High School/Homestay Program Student Application InstructionsYour application is very important. It is used in your placement with an American host family and thereforeshould reflect who you are—your interests, activities, likes and dislikes, and what you hope to gain from theprogram. Following is a checklist for you to use to verify that all parts of the application are completed.♦ Neatly type or print legibly in BLACK ink in English. Applications done in blue ink will be rejected.♦ If student’s parents need English translation, the sending organization in your country can provide a translation.♦ Responses to all questions should be honest and detailed.♦ The Host Family Letter is very important. Take the time to think about what you want to say as this will be a reflection of who you are. The letter is often the deciding factor in a family’s decision to host a particular student.♦ Photographs are also a very important part of your application. Be sure that photos show you happy and smiling. Photographs of you with your family, relatives, friends, pets, etc. are also very important and help to reflect who you are.The following check list is for your convenience. Please make sure that you have completed all items below. Initial Information Card. Please fill it out on your computer and EMAIL it as an attachment to ACES. Eight (8) SMILING, passport-size photos (approximately 2” X 2.5”). Be sure to SMILE !!! (Host families will choose a student who smiles over one who does not.) Student Profile Page. Student Letter to the Host Family. Student Questionnaire. Parent Information and Comments. Parent Letter to the Host Family. Student’s Academic and Educational Information. Teacher or School Counselor Recommendation. Academic Transcripts -- English Translation with a clear explanation of the grading system. Original Academic Transcripts for the past three (3) years. Medical Information/Immunization Record. Standards of Conduct/Travel Release/Authorization/Medical Care Release/ Liability Release/Agreement Release Photo pages of student’s family, friends, pets, special events, etc. Provide at least six (6) personal photographs that tell something about you. You can include photographs of you with family, friends, relatives, pets, etc.
  • 2. STUDENT PROFILE To be completed by the STUDENT FOR ACES OFFICIAL USE ONLY PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK STUDENT ID #: 11 12 Academic Year - 20____ / 20____ Program Participation: Fall Semester - 20____ Spring Semester - 20____ First Name: Vínicius Nickname: Vini Gender: Male Female 11 / 16 / 1995 Hometown: São Country: Brazil Date of Birth: Month Day Year Paulo Grade Level (Completed by ACES Office): Years of English in School: 10 Expected HS Graduation Date: 12 / 2012 Month Year Religion: Protestant Participation Level: Weekly Monthly Occasionally Never Do You Smoke? Yes No Can you adjust to living with a family that smokes in the home? Yes No Most host families have pets, mostly indoor dogs and/or indoor cats. Can you adjust to pets in the home? Yes No Your Pets (if any): None List any allergies that have been diagnosed by a doctor: None Family Information (Please list all who live in your home and all siblings who no longer live at home.) First Name Age Relationship Lives with you Married? Occupation English Level Ademir Father No No Car Salesman None Nalzira Mother Yes Yes Bank Manager Basic Evair Stepfather Yes Yes Sales Manager None Leandro Stepbrother Yes No Import Helper Fluent Five Favorite Interests (5 favorite interests currently or recently involved in, 1 to 5, “1” being most favorite.) Billiards/Pool Cooking Drama/Theater Music-classical Singing Board games Crafts Drawing/painting Music-popular Sewing/needlework Bowling Dance Gardening Playing an instrument Stamp/coin collecting Camping Type: Graphic Arts Specify: x Watching sports x Chess Discussing ideas x Movies x Photography/video Watching TV x Computers Discussing politics Museums/galleries Reading Other: Five Favorite Sports (5 favorite sports currently or recently involved in, 1 to 5, “1” being most favorite.) Aerobics/ Gym Fitness x Golf Kayaking/Canoeing Snow skiing x Volleyball Badminton Gymnastics Martial arts x Soccer Windsurfing Baseball Hiking Type: Surfing Water Sports: x Basketball Horseback riding Rollerskating/blading Swimming Specify: Bicycling Hunting Sailing Tennis Windsurfing Field Hockey Ice Hockey x Skateboarding Track/Running Wrestling Fishing Ice skating Snowboarding U.S. Football Other: Describe how often you participate in all sports, music or other activity in which you are CURRENTLY involved. Describe any sports, music, or other hobby achievements. I play soccer almost every day and the others sports I play once a month. Apart from soccer, I like to play chess, use the computer and I enjoy listening music of various styles, I am very eclectic. Do you hope to participate in sport(s) while in the program? Yes Yes any sports. No If “Yes” which sport(s)? ________________ I want to meet other sports and also play my favorites __________________________________________________________________________________________V. 2010 US High School/Homestay Exchange Program Application Page 1 of 21
  • 3. STUDENT PROFILE To be completed by the STUDENT 1. How would your friends describe you? Lively, intelligent, funny, talkative, organized, is always ready to help a friend. 2. Please describe the most important interest or activity in which you CURRENTLY participate and why it is important to you. I have nothing in particular that is so important but would like to play socce just for fun like other sports too. 3. Do you sing or play a musical instrument? If yes, what instrument(s) and how often do you play (daily, weekly, and monthly)? How many years have you played the instrument(s)? I dont play any instrument but I love who plays instrument. 4. What foods do you like and dislike? I like various kinds of meat, chicken, and some fish and pasta. I dont like many kinds of vagetables just like lettuce, tomatoes and cabbage. 5. Besides English, what other foreign languages have you studied? Please use additional paper if the following chart is not enough. How do you rate your ability, using E = excellent, G = good, F = fair, P = poor? Language Years Studied Reading Writing Speaking Listening Spanish 2 G P F G 6. Describe in detail your foreign travel, if any, and other international experiences. Indicate whether you traveled with or without your family. I did a cruise and used a lot of Spanish to communicate with people in Argentina so I learned a lot this language 7. How often do you interact with young children? Daily/Weekly Several times a month Occasionally No experience with young children What is your experience(s) interacting with children and what are the ages of the children? I have a 4 year old niece and I like to play with it, I am clumsy to bathe, feed or any of those responsibilities but I love to interact with it. 8. Most volunteer U.S. host families live in small towns or rural communities; you are likely to be placed in this environment. What will you do to adapt to this community? I dont care about being a small town is now a rural community, I have no experience but I will try my best to adapt. 9. What about your culture would you like to share/teach your host family and high school? I would like to show Brazilian music, Brazilian food, talk about Brazil, take pictures so you can see Brazil and take things from here typical. 10. Please describe any body piercings (except pierced ears), tattoos, or unnatural hair coloring I have nothing in my body. ______________________________ (Please note: Any student who arrives in the host community with piercings, tattoos or unnatural hair color not listed above will be placed on warning. While on the program, students are not allowed to have any piercings (including ears), tattoos or unnatural hair coloring done.) Additional Information (For ACES Office Use Only) English Test: Score: Tuition: Yes NoV. 2010 US High School/Homestay Exchange Program Application Page 2 of 21
  • 4. HOST FAMILY LETTER To be completed by the STUDENT Student First Name: Vínicius Country: Brazil Your letter to your host family is one of the most important parts of your application. You are strongly encouraged to spend time thinking about how to introduce yourself and show your potential host family who you are. This is your opportunity to show appreciation for being invited to become a member of your volunteer host family. You should include details about the following: your habits and likes interests and hobbies what you do with your family and friends your home community Add any additional information that will help your host family know and understand you better. Your letter should be a minimum of two full pages in length but please add additional pages if needed. Hello, My name is Vinícius Tolentino I am 15 years old, live in São Paulo SP my older brother did this exchange program and give that the idea has to do also. I live with my mother “Nalva”, my stepfather who is like a father to me “Evair” and with my stepbrother that already did the Exchange Program “Leandro”. In Brazil I like to do a lot of things like going out with friends to the movies, paintball, kart, bowling and play soccer with them, I like to surf the internet watching funny things,I like to play online games on computer and talking with my friends on msn, skype or facebook, use the internet to do school work and personal research also. With my family I like going to my aunt’s chacara and there like to play chess, pack, soccer and a lot others things that come to. When I am at home in routine use a lot of computer and play my Xbox360 or Playstation3 with my friends or relatives. I am communicative and get along well with people of all ages from children to seniors, I am a boy who fights for my goals,I like to entertain people,I am a good student in college,good grades and shot like a lot of the physical education class they play soccer with my friends. My stepbrother Douglas went to Canada to do English Course of a year, my only experience with a similar exchange was a cruise I did 8 days with my family, there I met several friends from other countries and had to speak Spanish, Portuguese and English and was a great experience for me. I hope you like me and support me in this challenge that is spending one year in a completely different place that I am used to and no relatives near, you are the ones who I can count.V. 2010 US High School/Homestay Exchange Program Application Page 3 of 21
  • 5. My signature below indicates that I have written the Host Family Letter by myself and without help and that the decision to participate in the program is my own. Student Signature DateV. 2010 US High School/Homestay Exchange Program Application Page 4 of 21
  • 6. STUDENT QUESTIONNAIRE To be completed by the STUDENT Student First Name: Vínicius Country: Brazil 1. Other than the benefit of improving your English, give three reasons why you want to participate in the program and live with an American host family? Make new friends, learn a culture different from the Brazilian and mature, I became more independent. 2. What accomplishment in your life so far are you most proud of and why? My family and friends who I have conquered. 3. What are your career goals? (If you are undecided, discuss possibilities that you are considering.) Be airplane pilot and know several places in the world. 4. Describe any volunteer activities or part-time jobs in which you have been involved. I am not involved with any volunteer activities. 5. Describe your relationship with your family and what activities you do together. We have a very good relationship, we traveled almost every weekend to a farm or beach, there I play video game, I play soccer and many other things.V. 2010 US High School/Homestay Exchange Program Application Page 5 of 21
  • 7. STUDENT QUESTIONNAIRE (Cont.) 6. What household chores/responsibilities do you have in your own home? Clean my room, take out the trash, make beds, clean the living room. 7. Living in a foreign country for 5 to 10 months is difficult. You must be able to adapt and be flexible in dealing with the many differences between the U.S. and your own country. a) Why do you feel you will be able to adapt? Because I am very communicative and I like challenges. b) Describe your past experiences adapting to new surroundings and situations. I never had many experiences but the little I had a week or a month ever succeeded. 8. You may be placed with a host family of a different social or economic standing than you are accustomed to. a) What do you think the challenges may be in living? Challenges are essential for you to become a mature person b) What do you think the benefits may be? I will gain greater responsibility and be more independent in many aspects. 9. At some time during your stay you will feel lonely and homesick. Communication with your home country family and friends often makes homesickness worse. How else will you overcome these feelings? I Always try to keep doing something and keep my mind busy, I will looking for people who can talk to me and dont let me keep thinking in Brazil.V. 2010 US High School/Homestay Exchange Program Application Page 6 of 21
  • 8. PARENT INFORMATION AND COMMENTS To be completed by the STUDENT’S PARENTS Student Name: Tolentino Vínicius Last(Family) First(Given) Middle Student’s Email: vi_saw@hotmail.com Father’s Name Mother’s Name Nalzira Chaves Caetano This is the student’s primary mailing address Yes No This is the student’s primary mailing address Yes No Rua Mariucha 51, apto 82 bloco B Address Address São Paulo City Postal Code São Paulo City Postal Code 02960030 Province/State São Paulo Province/State São Paulo Home phone Home phone 11-3932-7341 Cell phone Cell phone 11-7997-2700 Work Phone Work Phone Are you willing to pay tuition for your son/daughter to attend private school? Yes No If yes, what is the maximum tuition that you can pay? $ We, the undersigned parents/legal guardians, understand that we will be required to pay school tuition to attend a private school and we agree to pay up to the maximum stated above. _________________________________________ Parents/Legal Guardians Signature 1. Whose idea was it for your daughter/son to participate in the program? Why do you support your child’s participation? What do you hope he/she gains from the experience? Was from my others two sons and two nephews that participated in the program and had been successful and in the labor market of today who knows to talk in English have more chances to get a good job. 2. U.S. teenagers do household chores as a responsibility to their family. What responsibilities (duties, household chores, curfew, behaviors, etc.) does your son or daughter have in your family? He never had anything but an obligation has always done things basic as making a bed, clean room, clean the living room, having meals at times basic patterns and other activities.V. 2010 US High School/Homestay Exchange Program Application Page 7 of 21
  • 9. PARENT INFORMATION (Cont.) 3. Please describe your son’s/daughter’s personal qualities and characteristics. 4. How is your son/daughter unique? 5. Describe your relationship with your son or daughter. 6. How does your daughter or son usually express frustration or anger? How does she/he handle problems or adversity? 7. Your daughter/son will have to adapt to new situations quickly. Give examples of how your daughter/son has shown adaptability or adjusted to new situations in the past. 8. Please provide any additional information or describe special circumstances regarding your daughter/son which will help the host family be prepared to take care of her/him.V. 2010 US High School/Homestay Exchange Program Application Page 8 of 21
  • 10. PARENTS LETTER TO THE HOST FAMILY To be written by the STUDENT’S PARENTS Student First Name: Vínicius Country: Brazil Your letter to your son/daughter’s host family is an important part of the application. Please describe your son/daughter at length, including but not limited to his/her relationship with family and friends, personality traits, likes, etc. Please attach additional pages if necessary. Family Caetano, I am Nalzira Caetano mother of Vinicius Tolentino, we are a big family, in our family have Douglas (25 anos), Vanessa (23 anos), Leandro (17 anos) and Vinícius (15 anos), my husband is Evair Caetano (45 anos). Talk about Vinicius is easy, because he have many characteristics as communicative, affectionate, persistent and very determined. At school the teachers always praises his, as a student who easily assimilates the material, take good notes, so I strive to give the best for my son, and show him the importance of preparing for the world. Vinícius love internet, sometimes I need to ask him to go to the bed, but is very punctual to get up. On nutrition he is normal,despite eating little and stuff like surface, he likes steak, rice, beans, barbecue, cabbage, lettuce and he loves ice cream. I hope he is well with you and he learns a lot from you. Thank you. Bye Father’s Signature Mother’s Signature DateV. 2010 US High School/Homestay Exchange Program Application Page 9 of 21
  • 11. ACADEMIC AND EDUCATIONAL INFORMATION To be completed by the STUDENT 1. Date I began my 1st grade: (month/year) What is your current grade level at your school? (Please Note: Students from countries whose full academic program (beginning with first grade) is less than 12 years must NOT indicate that the final year of schooling in the home country is equivalent to 12th grade in the U.S.) 2 How many years of high school must you complete in your home country after the program and return home? Years 3. Do you understand that you are not guaranteed a high school graduation/diploma? Yes No 4. What is your favorite subject at school? 5. What is your least favorite subject at school? 6. Do you plan to go to college/university? Yes No If yes, what subject do you plan to study and where? 7. Describe your English language study. How many years in regular school? What age or school grade were you when you started studying English? How many class hours per week? 8. Have you studied English outside of your regular school? If yes, please describe your studies, and include how many years and how many hours per week. 9. American high school is both an academic and an extracurricular experience. ACES strongly encourages students to participate in sports, clubs and other activities. What do you expect to gain from your participation in an American high school?V. 2010 US High School/Homestay Exchange Program Application Page 10 of 21
  • 12. TEACHER RECOMMENDATION To be completed by the student’s TEACHER or SCHOOL COUNSELOR Thank you for completing this form. The applicant named below is applying to spend an academic semester or year attending a U.S. high school and living with an American host family. We appreciate your honest evaluation of the student. Student name _______________________________________________________________________________________________ Family First (Given) Middle Name of person completing form ______________________________ Number of years the student has attended your school _____ Name of school _____________________________________________________ Number of students in school _______________ How many years have you known this student? __________Year(s) In what capacity? _______________________________ Type of school (check all that apply) Private Public Religious Boarding Please rate the student in the following categories: EXCELLENT GOOD FAIR POOR Academic ability Academic performance Attitude toward school Study habits Initiative Emotional stability Maturity Adaptability/Flexibility Leadership capabilities Cooperativeness Friendliness Relationship with teachers and staff Relationship with classmates Potential as an exchange student How many years of school has the student completed, starting with first grade? ___________ What is the student’s expected date of high school graduation? _______________ month/year Does this student have a history of excessive absences from school? Yes No Don’t know Please discuss your above ratings of the student. How will this student adjust to the academic and social life of an American high school? Do you have any reservations about recommending this student for acceptance into our program? Signature: Date:V. 2010 US High School/Homestay Exchange Program Application Page 11 of 21
  • 13. ACADEMIC TRANSCRIPTS --- ENGLISH TRANSLATION To be completed by a SCHOOL OFFICIAL Student name _______________________________________________________________ Country _________________________ Family First (Given) Middle Recommended U.S. grade-level placement (no guarantee can be made for such placement). 9th 10th 11th 12th Name of person completing form ___________________________________________ Title _____________________________ In English, please list your school’s grading system next to the corresponding American grades listed on the left. U.S. Grading System Country Equivalent Comments or Explanation Excellent A Above average B Average C Below average D Failing F In English, please print the courses taken and the U.S. grade equivalent for the past three years, including current courses. If final grades are not yet available for the current courses, please list most recent ones. Applications received with fewer than 3 years of transcripts will be rejected. Hours per Final Hours per Final 20 ____/____ Grade Level _____ week grade 20 ____/____ Grade Level _____ week grade Hours per Final Please list courses the student should take while in the U.S. 20 ____/____ Grade Level _____ week grade No guarantee is made that the student will be able to take the courses. * Official transcripts for all three years must also be submitted with this form. Signature: Official Seal or Stamp:V. 2010 US High School/Homestay Exchange Program Application Page 12 of 21
  • 14. MEDICAL INFORMATION AND IMMUNIZATION RECORD To be completed, signed and dated by a PHYSICIAN Student Name: Date of Birth (Month/Day/Year): The applicant must have a physical examination by a licensed doctor, who is not a family member, within one year of coming to the U.S. The physician should complete the following on the applicant’s full medical history, current health, and immunization. Student Inoculation Record The student must have the following inoculations, before arrival in the U.S., in order to be admitted into a U.S. high school. Please note that some high schools may require additional inoculations or boosters before allowing a student to attend school. The cost for inoculations or boosters is not covered by health insurance and is the responsibility of the student. PLEASE NOTE: If the following (including all dates) is not completed in its entirety, the form will be returned to the student, which will cause a delay in placement. VACCINE AND DATE OF DOSE month/day/yr month/day/yr month/day/yr month/day/yr month/day/yr Polio (TOPV) / / / / / / / / / / DPT (diphtheria, tetanus, and pertussis) / / / / / / / / / / or TD (tetanus and diphtheria) / / / / / / / / / / TD Booster (tetanus and diptheria) / / Hepatitis A and B / / / / / / / / / / Measles (Rubeola, 10-day measles) / / / / Or date student had Measles: / / Mumps / / / / Or date student had Mumps: / / Rubella (3-day measles) / / / / Or date student had Rubella: / / Varicella (Chicken Pox) / / Or date student had Varicella: / / TB skin test (Mantoux) / / Results: Circle one. Positive* / Negative (no evidence of TB) * Chest X-ray (Required if TB Skin test is positive.) / / Results: Medical History 1. Has the applicant ever had a history of any of the following? If yes, please use an additional page to explain. Yes No Yes No Yes No Allergy (drugs, animals, food, etc.) Enuresis Rheumatic fever Appendicitis Headache (persistent, recurring) Rubella (year: ) Appendix has been removed Hepatitis Scarlet fever Asthma Hernia Seizure disorder Chicken pox (year: ) Malaria (year: ) Sleep disorder Goiter (Struma) Measles (Rubeola) (year: ) Tuberculosis Cough (persistent, recurring) Mumps (year: ) Vertigo, dizziness Diabetes Mellitus Parasites (intestinal, other) Eating Disorder Pneumonia 2. Any disease, impairment, or abnormality of the following? If yes, please use an additional page to explain. Yes No Yes No Yes No Abdominal/digestive system Gastrointestinal System Pelvic Blood, endocrine system Genito-urinary system Respiratory System Bones, joints, locomotor system Heart, blood vessels Skin (acne, etc.) Brain, nervous system Lungs, respiratory Teeth and gums Cardiovascular System Metabolic/Endocrine System Tonsils, throat, nose Ears, hearing Musculosketal Tonsils have been removed Eyes, vision Neuropsychiatric Varicose veins Other: 3. Has the applicant had any of the following? Yes No Yes No Yes No Restriction of a physical activity Treatment or counseling for a nervous condition, personality/ Difficulty with school, during the past five years? character disorder, eating disorder, or emotional problems? studies, or teachers? If “YES” was checked for any of the above, details MUST be provided by the physician. Please use additional sheet to provide the detailed information. Please use additional paper if needed.V. 2010 US High School/Homestay Exchange Program Application Page 13 of 21
  • 15. MEDICAL INFORMATION AND IMMUNIZATION RECORD (Cont.) Student Name: Date of Birth (Month/Day/Year): Medical Questions 4. List any hospitalization, significant past illness, or injury with diagnosis/descriptions and dates. 5. Is student now under treatment for any medical or emotional conditions? Yes No If yes, please explain. 6. If the student is currently taking any medication, list type and describe reason for medication. 7. Will the student need any orthodontic care during the coming year? Yes No Don’t Know (Note: Orthodontic work is NOT covered by the program health insurance and therefore the cost is the responsibility of the student should care be required during the program) 8. When was the date of the student’s last dental check-up? __________________ (Note: Dental care is not covered by program health insurance and therefore the cost is the responsibility of the student should care be required during the program) 9. Recommendations for physical activity: unlimited limited Please explain if limited. 10. Your opinion of the state of the student’s health: Excellent Good Fair Poor 11. Are you the applicant’s regular doctor? Yes No If no, please explain. 12. How long have you known/treated the applicant: ____________________________ Physical Examination of Student Student’s uncorrected vision: R_____/_____ L_____/_____ Does student wear glasses? ______ Hearing R_____/_____ With correction: R_____/_____ L_____/_____ Does student wear contact lenses? ______ L_____/_____ Urinalysis: Albumin ____________ Sugar ____________ Micro ____________ Hemoglobin _________________________ gms/% Height: _______________________ Weight: ____________________ Blood Pressure: _____________________________________ I, the undersigned physician, have reviewed the medical history of this applicant and given a thorough physical examination. I certify all important medical information has been included (attach separate sheets if necessary) and the above information is complete and accurate. Physician’s full name (Print) ______________________________________ Signature:____________________________________ Name of the clinic/hospital __________________________________________________________ Date:______________________ Complete address: ____________________________________________________________________________________________ ____________________________________________________________________________________________V. 2010 US High School/Homestay Exchange Program Application Page 14 of 21
  • 16. STANDARDS OF CONDUCT To be read carefully, signed, and dated by the STUDENT and BOTH PARENTS/LEGAL GUARDIANS ACES and its partners expect the highest standards of behavior from all program participants at all times and, in turn, assume responsibility for the welfare and safety of the student throughout the program. ACES and its partners work together to ensure that the student’s stay in the United States is as successful, safe, and secure as possible. The following Standards of Conduct have been established for that reason. Any violation of these rules will lead to disciplinary action and possible termination from the program. Any violations of local, state, or federal laws or serious misbehavior in the host family, high school, or community will result in dismissal from the program and early return to the home country at the expense of the student’s parents and with no refund of any program fees. • LOCAL, STATE, AND FEDERAL LAWS If a student is arrested, or if ACES determines it is reliably confirmed that the student has acted illegally, the student will be dismissed from the program and will be returned as soon as legally possible to the home country at the expense of the student’s natural parents. 1. Drinking of alcoholic beverages, including beer and wine, is not permitted while on the program and is illegal in most states for persons under 21 years of age. 2. Smoking is illegal in most states for persons under 18 years of age. If the student has stated in the application that he/she is a non- smoker, he/she must not smoke while in the U.S. If a student is found to be a smoker after having stated otherwise, he/she may be dismissed from the program and returned home. If the student is a smoker, he/she must comply with all smoking restrictions imposed by the host family, host school, any public or private venue, and state laws. 3. The student must not buy, sell, possess, or use illegal drugs of any kind or use any controlled drugs, unless prescribed for him/her by a physician or other health professional. If the student is taking prescription drugs, the English name, dosage, and length of time of use for each drug must be listed on the Medical Information Form. The student must not associate with any persons involved in illegal drug- taking or drug-possession. 4. The student must not commit or take part in any act of violence against another person or property. 5. Shoplifting and theft are illegal and may lead to criminal charges. 6. Driving a car without a driver’s license is illegal. 7. It is illegal for the student to be employed while in the U.S. The only exceptions are occasional odd jobs, such as yard work or babysitting. Such jobs must not interfere with school work or host family schedules, and the student must have permission from the host family. • HIGH SCHOOL PARTICIPATION High schools expect exchange students to maintain high academic standards and to participate actively in school life. Therefore, a student who is dismissed from school due to problems including but not limited to attendance, attitude, behavior, discipline, failing grades, or lack of effort will be terminated from the program and returned home immediately. 1. The exchange student is not guaranteed placement in a certain school or grade level, or that academic credit will be transferable, or that a diploma will be awarded at the end of the academic program. All such decisions are at the discretion of individual high schools and/or districts. Students’ grade level (9, 10, 11, or 12) in the U.S. will be determined by ACES in consultation with the host school and MUST be accepted by the student. Students from countries whose full academic program (beginning with first grade) is less than 12 years must NOT indicate on the application that the final year of schooling in the home country is equivalent to 12th grade in the U.S. Applications indicating this will NOT be accepted. The student must accept and respect all decisions made by a school and/or school district regarding school placement, grade placement, credit, graduation/diploma, sports/extracurricular participation, and any other decision for which the school has authority. A student who continues to lobby the school and/or district after a decision has been made will be placed on probation or sent home. 2. The student must obey all school rules, attend class regularly with no unexcused absences, take a full course load (English and American Studies classes are required), work hard in all classes, do all school and homework assignments, and maintain at least a “C” average with no “F” (failing) grades. 3. The student is responsible for all school fees. Such fees may include but are not limited to: tuition, fees, registration, books, lockers, laboratories, gym/physical education, yearbook, student activities, social events, etc. 4. School Counselors should only be consulted for academic or school-related issues. Students must not consult a school counselor for any issue not directly related to school/academics. Students needing assistance with a host family or other issue must consult with their Local Coordinator, Regional Director or the ACES national office. 5. The student may choose, at the student’s own expense, one of the following options for lunch on school days: a) bring a sack lunch from home; b) buy a lunch at school; or c) buy lunch off campus, if the school permits. ACES students are not allowed by ACES to receive free or reduced-price school lunches. Signature of father/legal guardian Signature of mother/legal guardian Signature of student DateV. 2010 US High School/Homestay Exchange Program Application Page 15 of 21
  • 17. PROGRAM STANDARS OF CONDUCT (Cont.) • HOST FAMILY PARTICIPATION All American Host Families are volunteers and receive no compensation for hosting a foreign student. Students must show their appreciation and gratitude to the host family for hosting them. Host Families participate in the program because of their desire to have a cross-cultural experience and learn about other cultures while sharing the American way of life with the foreign student. Program fees paid are used for administrative, supervisory, and insurance purposes. 1. No guarantee is made with regard to placement in a particular state, nor in a city of a certain size, nor in urban versus rural areas, nor with a particular type of family. A student who refuses a placement or requests a change in placement will be considered withdrawn from the program with no refund of program fees. 2. A private bedroom is not guaranteed. A separate bed/mattress is guaranteed. 3. The student must show respect to the host family at all times and must not exhibit any behaviors deemed by ACES to be inappropriate. The student must comply with all rules of the host family (e.g. curfews, chores, visitors, phone calls, computer and internet usage, etc.). 4. Personal Information: Students are not allowed to give information on their host family (including: host family names, address, phone number, email address) to anyone except the student’s natural family and must not post any of this information on a social networking internet site. 5. The student must keep the host family informed at all times of his/her whereabouts, whom he/she is with, and times of departure from and return to the host family’s home. Students must ask permission of the host family before making plans. 6. The student must not borrow money from the host family or from any other source. Nor may the student loan money to the host family or anyone else, including the host family. Natural parents are required to supply the student with an adequate amount of spending money at all times. We recommend a minimum of $250 per month. Students with insufficient personal funds at any time during the program face dismissal from the program and return to their home country. Students must arrive on the program with a minimum of two months of spending money. 7. The student must speak with the host family or with program officials (ACES Local Coordinator, Regional Director or National Office) about any problems or issues that arise. Students must not speak of the host family’s private affairs to school, community members or friends. • COMMUNICATION AND ELECTRONIC EQUIPMENT USAGE 1. Excessive communication with family and friends from home is very disruptive to the student’s adjustment. Therefore, communication by any means (phone, email, internet, messaging, etc.) with family and friends from home should be limited to no more than one hour every two weeks. Further limitations in communication may be necessary for students who have difficulty adjusting to the host family, school or community. Students should use an international/domestic calling card if possible for all long distance calls. 2. Students must not use computers or other electronic equipment (e.g. MP3/Ipod players, game players, etc.) in an inappropriate manner and must follow all host family, school and program rules regarding such equipment. Students are not allowed under any circumstances to: a) access websites containing pornography, chat rooms, or any other sites deemed inappropriate by the host family or program officials; b) post pictures and quotations from host family, school, or program officials deemed inappropriate by the host family, school or program officials. Students are allowed to have a personal computer or other electronic equipment as long as all rules are followed at all times. Failure to follow all program, school and host family rules concerning use of the computer/electronic equipment will result in the computer/electronic equipment being taken away from the student and returned only when the student departs the program to return to his/her home country. 3. Personal Mobile/Cellular: Students are allowed to have a personal mobile/cellular phone while on the program. Students with personal cellular phones must follow all program, host family, school and community rules regarding use of the phone, including limiting communication with family/friends from home to no more than a total of one hour every two weeks. Students who do not follow all rules will have their personal phone taken and held by ACES until the student departs the U.S. • VISTS AND STUDENT TRAVEL WHILE ON THE PROGRAM 1. Visits by members of the student’s biological family or by friends from his/her home country are very disruptive to the adjustment of the student and an inconvenience to the host family. Visits during the first semester of the program are not permitted, nor are visits for students on the one-semester program. Any visit during the program must have the prior written permission of program officials. 2. The student is not permitted to travel outside the local area by him/herself or with peers. The student is not permitted to hitchhike, whether alone or with companions. 3. Overnight travel with the host family, another family, a responsible adult, approved groups (e.g. school, church, exchange student, etc.) is permitted if prior consent is given by the host family. Any travel resulting in the student missing school must also have the permission of school officials and/or teachers. The host family and Local Coordinator must be informed of all such trips and have a phone contact to reach the student in case of an emergency. 4. If a student wishes to travel outside the United States during the program, he/she must have permission of ACES program officials. All required visas for another country and fees are the responsibility of the student. Before departing, the student must check with the ACES national office regarding procedures for re-entry to the U.S. Signature of father/legal guardian Signature of mother/legal guardian Signature of student DateV. 2010 US High School/Homestay Exchange Program Application Page 16 of 21
  • 18. PROGRAM STANDARDS OF CONDUCT (Cont.) • LIFE-CHANGING DECISIONS AND MISCELLANEOUS RULES 1. Students will not be permitted to make life-changing decisions, including but not limited to marriage, religious conversion, or other decisions with legal, political, religious, and/or social ramifications. 2. Students are to abstain from sexual behavior and activity. Students found to be pregnant or responsible for pregnancy will be sent home immediately. 3. The student may not withdraw from the program at any time without the permission of program officials. If the student leaves the program for any reason other than a legitimate emergency (death or serious illness in his/her immediate family), he/she may not return to the program and will not receive a refund of any fees. 4. If the student is transferred from one host family to another for any reason, any transportation costs incurred are the responsibility of the student. 5. Students are not allowed to have any piercing or tattoos done while on the program, or to color their hair an unnatural color (the only exception to coloring hair is temporary coloring for a school or other event). 6. The student is responsible for his/her personal property. Any lost, stolen or damaged personal property of the student, including money, is the responsibility of the student and is not covered by any insurance policy. 7. Students are NOT allowed to enter the U.S. without notifying ACES. If the student arrives without ACES knowledge and consent they will be immediately cancelled. A full flight itinerary from home country to the ACES designated airport must be submitted to ACES national office at least five (5) business days before the departure. 8. Students are not allowed to take TOEFL, SAT, ACT, or any other non-program related examinations without ACES permission. • RETURNING HOME AT THE END OF THE PROGRAM 1. The student must return to his/her home country at the end of the program, which is 10 days after the completion of the academic term for which he/she was enrolled. 2. If a student leaves a host family or the U.S. and has any outstanding debts (such as medical bills not covered by insurance or long distance telephone calls), the student’s biological family will be responsible for payment of these debts in addition to a $150 surcharge to cover the costs of collection by U.S. program officials. • DRIVER’S EDUCATION AND DRIVING A MOTORIZED VEHICLE Because of the danger and liability involved in driving a motorized vehicle, the student may not drive any car, motorcycle, or other motorized vehicle for which an operator’s license is required. Participation in high school Driver’s Education courses or the acquisition of a driver’s license while on the program is not guaranteed. 1. Driving a driver’s education vehicle while accompanied by a qualified instructor as part of a Driver’s Education course in high school or a private driving school may be permitted. However, the student must use a vehicle provided by the course, and not use the host family’s or other private car. The cost of any driving course is the responsibility of the student. 2. If the student obtains a driver’s license while on the program, the license must be surrendered to the Local Coordinator until the student departs the U.S. It is illegal to drive a car in the U.S. without a driver’s license. 3. The student may not use the host family’s car or anyone else’s for a driver’s education course, driving practice or for any other reason under any circumstances. The student is not allowed to rent or purchase a car or any motorized vehicle while on the program. • AGREEMENT TO ABIDE BY THE PROGRAM STANDARDS OF CONDUCT We, the undersigned (student and parents/legal guardians), have read and understand all of the above stated in the High School/Homestay Program Standards of Conduct. I, the student, agree to obey the Standards of Conduct and all rules set by the school, Host Family or program officials, even if I am or will be 18 years of age on the program. We, the parents, agree that our son/daughter will obey the Standards of Conduct and all rules set by the school, Host Family or program officials, even if he/she is or will be 18 years of age on the program. We understand that violation of these Standards of Conduct or of any rules set by the school, Host Family or program officials may lead to disciplinary action and possible termination from the Program, which may result in an early return to the home country at the parents’ expense and with no refund of program fees. We further understand and agree that ACES has sole discretion in making any decisions regarding termination of the student from the program and repatriation of the student to his/her home country. We also understand that when the decision is made to terminate a student from the program, the student’s visa status will be revoked and ACES will notify the proper U.S. Government authorities of termination of sponsorship. ___________________________________________ __________________________________________ ________________ Signature of father/legal guardian Print father’s/legal guardian’s full name Date ___________________________________________ __________________________________________ ________________ Signature of mother/legal guardian Print mother’s /legal guardian’s full name Date ___________________________________________ __________________________________________ ________________ Signature of student Print student’s full name DateV. 2010 US High School/Homestay Exchange Program Application Page 17 of 21
  • 19. TRAVEL RELEASE/AUTHORIZATION To be read, signed, and dated by the STUDENT and BOTH PARENTS/LEGAL GUARDIANS We, the undersigned (parents/legal guardians), authorize our child to travel within the guidelines as established in the Program Standards of Conduct and accept full responsibility for our child’s participation in any approved travel activities and indemnify and hold harmless ACES and its partners in the U.S. and foreign countries, their designated agents/representatives, Local Coordinators, Regional Directors, Host Families and other involved in the program from any claims and/or liabilities to third parties arising from our child’s participation. We also understand that our child must return to the home country at the end of the program (which is within 10 days after the completion of the academic term in which the student is enrolled). We also understand that if our child is dismissed from the program, he/she must return to the home country immediately. It is understood that this Travel Release/Authorization is signed in advance and eliminates the necessity of obtaining our signatures at the time of any Program-approved travel for the duration of our child’s participation in the High School/Homestay Program. ________________________________________ ___________________________________________ __________________ Signature of father/legal guardian Print father’s/legal guardian’s name Date ________________________________________ ___________________________________________ __________________ Signature of mother/legal guardian Print mother’s/legal guardian’s name Date MEDICAL CARE RELEASE LIABILITY RELEASE AGREEMENT RELEASE To be read, signed and dated by the STUDENT and BOTH PARENTS/LEGAL GUARDIANS In case of illness, accident, or injury we grant permission to examine and treat our child, whose signature appears below, at an appropriate medical facility and to make referrals to outside physicians and facilities as indicated. We also authorize ACES and its representatives and host families to act for us in any emergency, accident or illness during the period of time the student is in the ACES program. We grant permission to release information regarding our child’s health to any individual designated by ACES, its partners in the U.S. and foreign countries, and its agents or representatives. We also grant permission for our child to receive any and all immunizations, which are not covered by ACES insurance, required by federal, state, local, or school authorities for participation in the High School/Homestay Program. While under the sponsorship of the Program, the student may not participate in skydiving, hang gliding, glider riding, parachute jumping, parasailing, motorcycle riding, hot air ballooning, scuba diving, mountaineering, outdoor rock climbing, bungee jumping, and/or any activity that program officials define as high-risk activity. I/We accept full responsibility/liability for my/our child’s participation in the activities that are specified below. Please check (√ ) all activities in which you DO NOT allow your child to participate. Drive/operate tractor or other farm equipment Sailing Drive snowmobile Snow boarding/snow skiing Drive motorboat or other power driven water vessel Snorkeling (free) diving Drive All Terrain Vehicle (ATV) Surfboarding Hunting Swimming Jet-Skiing Wall climbing Kayaking Water skiing Ride in private planes Wind surfing Riding horses Other activity, please specify:V. 2010 US High School/Homestay Exchange Program Application Page 18 of 21
  • 20. MEDICAL CARE RELEASE LIABILITY RELEASE AGREEMENT RELEASE (Cont.) In anticipation of my son’s/daughter’s acceptance to participate in a program sponsored and/or arranged by ACES or its partners in the U.S. or foreign countries, we, the undersigned (student and parents/legal guardians), hereby release American Cultural Exchange Service, its partners in the U.S. or foreign countries, Regional Directors, Local Coordinators, American Host Families, American High Schools from any and all current and future claims, charges, costs, and/or causes of action for loss of property, personal injury, illness, accident, or death sustained by my child during the time he/she is a participant in the Program, whether covered by current insurance or not. We further agree to indemnify and hold harmless all of the above-named from any and all liabilities, including liabilities to third parties, which may arise from my child’s participation in the Program, including all activities specified herein, in the Standards of Conduct, and elsewhere. We, the undersigned, authorize the U.S. high school, medical, legal, government, and/or law-enforcement authorities to release to Program Officials any records or information necessary to provide the student with appropriate supervision and guidance. We, the undersigned, grant Program Officials permission to use photographs or any other materials in which the participant may appear for promotion or publicity of this or future programs. We, the student and parents/legal guardians, certify that all information provided in the Student Application is correct and complete, including medical and immunization history. We also understand that any changes in the information provided in the Student Application, including but not limited to changes in the applicant’s medical history or condition, must be reported to ACES immediately. We understand that withholding information and/or providing incorrect information and/or not reporting changes after the application is submitted are grounds for termination from the program and repatriation at the parents’ expense with no refund of program fees. We also understand that changes in the applicant’s information may lead to the applicant being cancelled from the program and that ACES has sole discretion to change the student’s acceptance status based on any new or changed information provided after submission of the application. We, the undersigned, understand and agree that ACES has sole discretion in determining whether our child’s health meets the minimum required for participation in the program. We also understand and agree that if our child’s health condition changes while on the program, ACES has the sole right to determine if his/her health still meets the required minimum and if not, that our child will be required to return home. This agreement covers the period from the time when our child is accepted to the ACES program until he/she leaves the program or is terminated from the program. The signature of the undersigned applicant/participant and parents/legal guardians indicates a complete understanding of the above Program Standards of Conduct, Travel Authorization, Medical Care Release, and Agreement/Liability Release and a willingness to abide by said Program Standards of Conduct, Travel Authorization, Medical Care Release, and Agreement/Liability Release. If we, the undersigned, do not sufficiently understand English, we have requested from ACES’ representative in my country a translation in our native language of the Program Standards of Conduct, Travel Authorization, Medical Care Release, and Agreement/Liability Release to ensure that we understand the information stated herein. _________________________________________ __________________________________________ ___________________ Signature of father/legal guardian Print father’s/legal guardian’s full name Date _________________________________________ __________________________________________ ___________________ Signature of mother/legal guardian Print mother’s/legal guardian’s full name Date _________________________________________ __________________________________________ ___________________ Signature of student Print student’s full name DateV. 2010 US High School/Homestay Exchange Program Application Page 19 of 21
  • 21. STUDENT PHOTOGRAPH ALBUM Student Name: To be completed by STUDENT Please attach photographs of you with your family, home, friends, pets, etc. You may add additional pages of photographs if desired. Describe: Describe: Describe:V. 2010 US High School/Homestay Exchange Program Application Page 20 of 21
  • 22. STUDENT PHOTOGRAPH ALBUM (Cont.) Student Name: Describe: Describe: Describe:V. 2010 US High School/Homestay Exchange Program Application Page 21 of 21