2013-2014 Student Application - Ayusa Student Application... · The student should demonstrate a strong desire to integrate into the host family lifestyle. All Ayusa host families

Name

Program Type:

Nationality

Overseas Partner

o oAcademic Year Fall Semester

2013-2014 Student Application

1

General Instructions

• Pleaseuseblackinktocompletethisapplicationandbesuretowriteclearly.

• Eachsectionoftheapplicationisintendedforadifferentpersonorgroupofpeopletofillout.

• PleasereadtheinstructionsforeachsectioncarefullyandaskyourAyusaAgentifyouareunsureofanythingbeforeyoubegintofillouttheapplication.

• AllsectionsoftheapplicationmustbecompletedinEnglish.

• PleaseremoveanystaplespriortoreturningtheapplicationtoyourAyusaAgent.Donotpasteanythingotherthanphotosinthephotoalbumsectionanddo not include or use any binders.AyusaHeadquartersstaffmustbeabletofeedtheapplicationintoaphotocopier.

• Onlycompleteapplicationswillbeconsideredforadmissiontotheprogram.

Part 1: Student Section - pages 3-8 (ToBeCompletedByTheStudent)

• Headshot Photos Instructions:Pleaseattach2smilingheadshotphotos,4.5x3.5centimeters.Yourfaceshouldbeclearlyvisiblewithoutanythingcoveringit.Itisimportantthatyouaresmilinginthephoto,evenifyouarenotaccustomedtotakingphotosthisway.

• Biographical Information Instructions: ThisinformationisusedtogenerateyourDS-2019CertificateofEligibilitywhichyouwillneedinordertoapplyforyourJ-1visa.Pleaseensurethatthisinformationislegibleandaccurate.

• Getting to know you Instructions: ThesepageswillhelpAyusastafftobecomefamiliarwithyourinterestsandhabits.Itwillalsohelptointroduceyoutopotentialhostfamilies.

• Short essays Instructions: Pleasewriteatleast3complete,thoughtfulsentencesforeachquestion.

• Student Letter Instructions: PleasewritealetterinEnglish,printedlegiblyinblackink.Thelettershouldnotexceedthespaceprovidedonthepage.Thislettershouldbeaddressedtothehostfamilymemberswhowillsharetheirhomewithyouduringyourprogram.Pleasebeasthoroughaspossiblesothatthehostfamilywillhaveagoodun-derstandingofyou,andanswerallthequestions.Lastly,pleasedonotwriteyourlast/familyname,hometownornameofschoolinyourletter;thisisforconfidenti-alitypurposespriortotheconfirmationofyourplacement.Pleaseanswerthesequestionsinyourletter:

1. Whatdoyouwantthehostfamilytoknowaboutyou?

2. WhydoyouwanttoattendhighschoolandliveintheU.S.withanAmericanfamily?

3. Whatisyourlifelikeinyourhomecountry(relationshipswithfamily,home,friends,school)?

4.Whatplansdoyouhaveforyourfutureeducationandcareer?

• Passport Copy or Birth Certificate Instructions: Insertaphotocopyofyourpassportorbirthcertificateinthissection.Makesureyourbirthdateisclearinthecopy.

• Host Family/Community Placement Agreement Instructions: Studentmustsign.

Part 2: Parent Section - pages 9-12

(ToBeCompletedByTheStudent’sParent(s)

•Family Information

• In the Case of an Emergency Instructions:Contactmustnotbeparent.

• Medical Release Authorization Instructions:Parentmustfillout.

• Parent Letter InstructionstoParents:Pleasewritealetter,printedlegiblyinblackink,ortyped,andwriteinEnglishifpossible.Thislettershouldbeaddressedtothehostfamilywhowillsharetheirhomewithyoursonordaughterduringhis/herprogram.Pleasebeasthoroughaspossiblesothatthehostfamilywillhaveagoodunderstand-ingofyoursonordaughter.Describeyourteenager’spersonalityandcharacterandanswerthesequestions:

1. Whatdoyouwantthehostfamilytoknowaboutyoursonordaughter?

2. Whathelpfuladvicecanyouoffertohelpthehostfamilybetterunderstandyoursonordaughter?

3. Whatmightbechallengingforyourson/daughterintheU.S.?

• Consent to Take Driver’s Training Instructions:ParentsmustreadtheConsenttoTakeDriver’sTrainingsectioncarefully.Checkoneoftheboxesandsigntheconsenttoeitherallowyourson/daughtertotake,orprohibityourson/daughterfromtakingaDriver’sTrainingCourse.

• Private High School Option Instructions:Parentmustfillout.

• Permission to Participate Instructions:Parentmustsign.

• Host Family/Community Placement Agreement Instructions:Parentmustsign.

2

Part 3: Academic Section - pages 13-15

(ToBeCompletedByTheStudent’sEnglishTeacherAndSchoolOfficial)

• English Teacher Recommendation Instructions:ThisimportantdocumentwillhelpyoutogainentranceintoanAmericanhighschool.YourcurrentEnglishteachershouldprovideathoroughandhon-estassessmentofyourEnglishcapabilities.

• School Official Recommendation Instructions:Aschoolofficial(otherthantheEnglishteacher)mustcompletetheSchoolRecommendation,andsigntheSchoolOfficialAgreement.

• Official Transcripts Instructions:Youmustobtainandsubmitofficialtranscripts,includinggrades,foryourlastthreefullyearsofschool.Youmayincludegradesforclassesyouarecur-rentlyattending.IncludeJuniorhighschoolormiddleschooltranscriptsifnecessary.Inserttheofficialtranscriptsinthissection.

Part 4: Health Section - pages 16-20 (ToBeCompletedByAPhysicianWhoIsNotRelatedToTheStudent)

Instructions:Pleasebringthissectionwithyouwhenyougotoyourdoctorforanexamination.Allquestionsmustbeanswered,andasdetailedaspossible.

•Health Statement

•Health Basics

•Allergy Details

• Immunization Record Instructions:Thisinformationmustbecomplete;ifnot,indicatewhenstudentwillbecompletingimmunizations.

• Physician Agreement / Conclusion Instructions:Physicianmustsign.

Part 5: Ayusa Overseas Partner Section - pages 21-26

(ToBeCompletedByTheStudent’sAyusaOverseasPartner)

• Program Information Instructions:Pleasespecifywhichprogramthestudentisapplyingforandthepreferreddepartureairport.

• Student Interview Instructions:Priortotheinterview,pleasereviewtheAyusaStudentHandbooksoyouarefamiliarwithourpoliciesandprocedures.Theinterviewmustbeconduct-edprimarilyinEnglishandinperson.PleasekeepinmindthatstudentsshouldnotcometotheU.S.onlybecausetheirparentswantthemto.Thestudentshouldbeinterviewedseparatelyfromhis/hernaturalparents.Also,itisimportanttodeterminethestudent’slevelofmaturityandflexibilitytoadjusttolivingwithanAmericanhostfamily.Thestudentshoulddemonstrateastrongdesiretointegrateintothehostfamilylifestyle.AllAyusahostfamiliesarevolunteers;assuch,itisthestudent’sresponsibilitytoadapttothehostfamily,highschool,andAmericanwayoflife.Asyourdiscussiondevelopsfeelfreetoaskthequestionsinanyorder,butmakesuretoprovideanswerstoallquestions.

• Grade Conversion Chart Instructions:Pleaseenterthestudent’sgradesasrepresentedontheofficialtranscripts,andthenconvertthegradestotheU.S.equivalent.Alsofillinthegradingscalecharttocorrespondtoeachyearofschool.Pleaseindicatewhetherthelastyear’stranscriptsarecompleteacademicyeartranscriptsorprogressreports.

• SLEP test Instructions:PleasecarefullyfollowalloftheinstructionsforadministeringtheSLEPtestasoutlinedintheSLEPTestManual.BesuretoincludetheoriginalscoredSLEPtestwiththeapplication.

• Ayusa Overseas Partner Agreement Instructions:AyusaOverseasPartnermustsign.

Part 6: Ayusa International Program Agreement - pages 28-33

(ToBeCompletedByTheStudent,Student’sParents,AndAyusaAgent)

• ProgramAgreement

• Smoking/DrinkingAgreements

• DoublePlacementAgreement

Part 7: Photo Album - pages 34 -35 (ToBeCompletedByTheStudent)

• Minimum of 4 photographs Instructions:Select4-8picturesofyou,yourfamilyandfriendsintheplacesyouliveorfrequentlyvisit,doingthethingsyouusuallydoorliketodo.Eitherprintthemoutonacolorprinterorpastethemonapieceofpaper.Onthepaper,writeanexplanationabouteachpicture,capturingthetruespiritofyourdailylife.Thealbumwillgiveyourhostfamilyanunderstandingofyourfamily,homeandlifestyle.Pleaserepresentyourselfpositivelyandfeelfreetoexpressyourcreativity.

Student ApplicAtion

STUDENT SECTION

pARt

3 www.ayusa.org

1 3 52 4 6 7Student Parent Academic Health Overseas

PartnerProgram

Agreements Photos

BIOGRAPHICAL INFORMATION

1)FAMILYNAME ______________________________________ FIRSTNAME _________________________________________

MIDDLENAME ______________________________________ NICKNAME __________________________________________

2)GENDER:oFEMALEoMALE

3)BIRTHDATE:MONTH__________________________DAY ________________ YEAR _________________________________

4)CITYOFBIRTH________________________________COUNTRYOFBIRTH _________________________________________

5)COUNTRYOFCITIZENSHIP ________________________________________________________________________________

6)COUNTRYOFLEGALPERMANENTRESIDENCE ________________________________________________________________

7)ADDRESS_______________________________________________________________CITY ____________________________

PROVINCE_____________________________________________ POSTAL/ZONECODE_________________COUNTRY _______________________________

8)PREFERREDAIRPORT ________________________________________________________________________________________________________________

9)HOMETELEPHONENUMBER:COUNTRYCODE ________________CITYCODE_______________PHONENUMBER___________________________________

10)E-MAIL____________________________________________________________________(Emailisusedforupdates/newslettersduringtheprogramyear)

GETTING TO KNOW YOU

1) Personality Characteristics: Check the box which most accurately represents your personality on the scale provided from 1 to 5.

1 2 3 4 5

Adaptable/Flexible o o o o oAppreciatesRoutines

Mature o o o o o YoungforHis/HerAge

Independent o o o o oNeedsGuidance

Open-minded o o o o oHasStrongOpinions

SenseofHumor o o o o oSerious

Sociable o o o o oReserved

Active o o o o oLow-key

2) Interests and Hobbies

Checkallboxesthatdescribeyourcurrentinterestsandhobbies:

1A

1B

oBadminton

oBand/Orchestra

oBasketball

oBikeRiding

oBoardGames

oChoir/Singing

oChurchActivities/Clubs

oCommunityService

oComputerScience/Technology

oCooking

oDance(formal)

oDebating

oDrama/Theater

oFishing

oFitness

oGardening

oGymnastics

oHandball

oHiking

oHorsebackRiding

oIceHockey

oMusic

3)Oftheabove,whichthreearemostimportanttoyou?___________________________________________________________________________

4)WhichactivitiesdoyouhopetocontinuewhileintheUnitedStates?______________________________________________________________

oMartialArts

oPainting/Drawing

oPhotography

oPlayingCards

oPolitics

oReading

oRunning/Jogging

oSailing

oSewing

oSkiing/Snowboarding

oSoccer

oSwimming

oTableTennis

oTennis

oVisitingmuseums

oVolleyball

o ___________________

o ___________________

o ___________________

o ___________________

o ___________________

o ___________________

Attach Photos Here

Do not staple or paste

3.5cm x 4.5cm

Student ApplicAtion

STUDENT SECTION

pARt

4 www.ayusa.org


PartnerProgram

Agreements Photos

(continued)

Lifestyle, Health, and Beliefs

5)Whatareyourhouseholdresponsibilities? ______________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

6) Doyouhaveacurfewathome?oYesoNo

Ifyes,whattimeisyourcurfewduringtheweek?_____________________onweekends? ______________________________________________________

7)Howmuchtimedoyouspendstudyingathomeperweek? ________________________________________________________________________________

8)Areyouwillingtoliveinahomewhereotherpeoplesmoke?oYesoNooItdepends ________________________________________________

9)Doyouhaveanypetsathome?oYesoNoIfyes,whatkindofpets? ________________________________________________________________

10)Areyouabletoliveinahomewithpets?oYesoNo

Ifno,pleasedescribewhy.Pleasebeasdetailedaspossible. _____________________________________________________________________________

11)Haveyoueverlivedawayfromyourparents?oYesoNoIfyes,pleaseexplain. _______________________________________________________

_____________________________________________________________________________________________________________________________________

12)Haveyoueverlivedortraveledoutsideyourcountry?oYesoNoIfyes,where? ______________________________________________________

13)Haveyoupreviouslybeenonastudentexchangeprogram?oYesoNoIfYes,didyouhaveaJ1orF1Visa?oYesoNo

14)Doyoufollowaspecialdiet(e.g.vegetarian,lactose-free)?oYesoNoIfyes,pleaseprovidedetails _____________________________________

_____________________________________________________________________________________________________________________________________

15)Areyouabletopreparemealsforyourselfifthehostfamilyisunabletodothisonsomeoccasions?oYesoNo

16)Listyournativelanguage(s):_______________________________________________

Indicatetheotherlanguagesyouspeakandthenumberofyearsstudied:

Language___________________________________YearsofStudy_______________



17)Whatisyourreligiousaffiliationordenomination?Ifyoudonothaveone,pleaseleaveblank.

18)Ifyoudoparticipateinreligiousactivities,pleaseindicatehowfrequently:

oEveryDayoOnceperweekoOncepermonthoRarelyoNever

19)HowactivelywouldyouliketopursueyourreligionwhileintheUnitedStates?

oEveryDayoOnceperweekoOncepermonthoRarelyoNever

1B

Student ApplicAtion

STUDENT SECTION

pARt

5 www.ayusa.org


PartnerProgram

Agreements Photos

SHORT ESSAYS

1)Haveyouvolunteeredorparticipatedincommunityservice?Pleasedescribeyourparticipation,andif/howyouwouldliketoparticipateintheUnitedStates.

2)Whatdoyouthinkwillbethemostchallengingpartofbeinganexchangestudent?

3)IfyouexperiencehomesicknessintheUnitedStates,howdoyouplanondealingwithit?

PLEASE PRINT CLEARLY. ANSWERS SHOULD BE AT LEAST 3 SENTENCES.

1C

Student ApplicAtion

STUDENT SECTION

pARt

6 www.ayusa.org


PartnerProgram

Agreements Photos

(continued)

4)Describeatimewhenyouweresadorupset.Whathappenedandhowdidyouovercomethis?

5)Describeindetailaninterestoryourparticipationinanactivitythatyouenjoy.Whatdifferencehasitmadeinyourlifeandinthelivesofothers?

6)Whatareyourfutureacademicand/orcareergoals?

1C

Student ApplicAtion

STUDENT SECTION

pARt

7 www.ayusa.org


PartnerProgram

Agreements Photos

HOST FAMILY/COMMUNITY PLACEMENT AGREEMENT

Iunderstandthereisno“perfect”hostfamilyorcommunityandIampreparedtoacceptthehostfamilyorcommunityAyusaselectsforme.

______________________________________________________________________________________________________________________________

StudentSignature Date

(continued)

7)Whatdoyouplanonpursuingand/oraccomplishingwhileintheUnitedStates?

8)Whatareyourbestcharactertraits?

1C

Student ApplicAtion

STUDENT SECTION

pARt

8 www.ayusa.org


PartnerProgram

Agreements Photos

STUDENT’S LETTER

PleasewritealetterinEnglish,printedlegiblyinblackink.Thelettershouldnotexceedthespaceprovidedonthispage.Pleaserefertothegeneral

instructionsforwhattoincludeinyourstudentletter.Do not include your last name, the name of your hometown or school.Thisletterwillbeused

byyourfuturehostfamilytohelpthemdetermineifyouarearightfitfortheirfamily.Pleaseprintclearly.

____________________________________________________________________________________________________________________________________

Dear Host Family,

1D

Student ApplicAtion

PARENT SECTION

pARt

9 www.ayusa.org

1 3 52 4 6 7Student Parent Academic Health Program

Agreements PhotosOverseas Partner

FAMILY INFORMATION

1)FATHER: LASTNAME____________________________________FIRSTNAME_______________________________OCCUPATION_________________________________

COUNTRYCODECITYCODEPHONENUMBER

WORKPHONE__________________________________________________________________________________________________________________________________

HOMEPHONE __________________________________________________________________________________________________________________________________

MOBILEPHONE _________________________________________________________________________________________________________________________________

E-MAIL ________________________________________________________________________________________________________________________________________

2)MOTHER: LASTNAME___________________________________FIRSTNAME______________________________OCCUPATION_________________________________

COUNTRYCODECITYCODEPHONENUMBER

WORKPHONE _________________________________________________________________________________________________________________________________

HOMEPHONE __________________________________________________________________________________________________________________________________

MOBILEPHONE ________________________________________________________________________________________________________________________________

E-MAIL ________________________________________________________________________________________________________________________________________

3)STUDENTLIVESWITH:oBOTHPARENTSoMOTHERONLYoFATHERONLYoOTHER: ______________________________________________

4)PARENTSARE:oMARRIEDoSEPARATEDoDIVORCEDoOTHER: _______________________________________________________________

Ifseparated,divorced,orotherwaschecked,whoislegallyresponsibleforstudent? ________________________________________________________

5)Listotherfamilymemberswholiveinthehome(brothers,sisters,grandparents,etc).

NAMEAGEGENDERRELATIONSHIP

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

6)Pleaselistanymedicationorsupplements,eitherover-the-counter(doesnotrequireaprescription)orprescriptionthatyoursonordaughteriscur-

rentlytaking,evenifinfrequently.Forwhatreasondoesyoursonordaughtertakethismedication?Howfrequently?

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

IN THE CASE OF AN EMERGENCY

Ayusarepresentativeswilldoeverythingpossibletocontactthestudent’sparentsincaseofemergency.Pleaseprovidethenameofanadditionalcontact

incasetheparentscannotbereached.

1)NAME(MUSTBESOMEONEOTHERTHANNATURALPARENT): ___________________________________________________________________________

2)COUNTRYCODE___________________CITYCODE___________________PHONENUMBER _____________________________________________________

3)DoyouknowanyoneintheU.S.whocanbecontactedincaseofemergency?oYesoNo

Ifyes,pleaseprovidethename,addressandphonenumber(s).

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

4)Pleaseusespacebelowforadditionalinstructionsand/oradvice.

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

STUDENTNAME:___________________________________________

2A

2B

Student ApplicAtion

PARENT SECTION

pARt

10 www.ayusa.org



2C MEDICAL RELEASE AUTHORIZATION

Medical Release Authorization:IherebyauthorizeAyusa,thehostparentsandtheCommunityRepresentative,withoutliabilityorexpensetothemselves,totakewhateveractiontheydeemappropriatewithregardtomyson’sordaughter’shealthandsafety.Theymayplacemysonordaughterinahospitalformedicalservicesandtreat-mentor,ifnohospitalisreadilyavailable,mayplacetheminthehandsofalocalmedicaldoctorfortreatment.Ialsoauthorizeanyphysiciantoreleaseanyinformationacquiredinthecourseofexaminationortreatment.IunderstandthatIwillberesponsibleforanycostsaccruedduetomedicaltreatmentthatisnotcoveredbytheinsurancepolicy.Icertifythattheaboveinformationiscorrecttothebestofmyknowledge.ThisauthorizationshallbevalidfortheentiredurationoftheAyusaprogram.PleasenotetheStudentApplicationandAdmissionSectiononpage28oftheProgramAgreementregardingstudent

medicalinformationdisclosures.

PARENT/GUARDIANNAME:_________________________________________________________________________________________________

PARENT/GUARDIANSIGNATURE:_________________________________________________________DATE:______________________________

STUDENTNAME:___________________________________________

Student ApplicAtion

PARENT SECTION

pARt

11 www.ayusa.org



2D PARENT LETTER(S)

PleaseinsertParentLetter(s)inthissection.PleaserefertotheinstructionsontheGeneralInstructionspageforguidanceaboutwhattoincludeinthe

letter.Pleasealsoconsiderthefollowingquestionwhenwritingyourletter:WhatwouldapotentialHostFamilyappreciateaboutyoursonordaughter?

__________________________________________________________________________________________________________________________

Dear Host Family,

Student ApplicAtion

PARENT SECTION

pARt

12 www.ayusa.org



2E

2G

2F

CONSENT TO TAKE DRIVER’S TRAINING

Astheparentoftheapplyingstudent,IunderstandAyusa’srulesregardingdrivingmotorvehicles.Iunderstandthatmysonordaughterisnotguar-

anteedtherighttotakedriver’strainingandthatAyusastudentscanonlytakedriver’strainingifitisinaccordancewithstatelawsand/orlocalschool

policy.Ialsounderstandthatmanyschooldistrictsdonotallowexchangestudentstoparticipateindriver’s

training.

oIgivepermissiontomyson/daughtertotakeDriver’sTrainingifitisavailableandifitisinaccordancewithstatelaws.

oIdonotgivepermissiontomyson/daughtertotakeDriver’sTraining.

ParentSignature:______________________________________________________Date:_______________________________________________

PRIVATE HIGH SCHOOL OPTION

1)Areyouwillingtopaytuitionforprivatehighschoolforyourson/daughter?oYesoNo(Indicating“yes”mayleadtoaprivateschoolplacement.)

2)Pleaseindicatetherangeoftuitioncoststhatyouarewillingtopay:

o $150-$300permonth

o $300-$500permonth

o $500-$750permonth

omorethan$750permonth

PERMISSION TO PARTICIPATE

Myson/daughterhasmypermissiontoapplyfor,andtoparticipatein,aninternationalstudyexperiencesponsoredbyAyusa

International.

ParentorGuardianSignature:____________________________________________Date:_______________________________________________

HOST FAMILY/COMMUNITY PLACEMENT AGREEMENT

Iunderstandthereisno“perfect”hostfamilyorcommunityandIagreetoacceptthehostfamilyorcommunityAyusaselectsformysonordaughter.

______________________________________________________________________________________________________________________

ParentSignature Date

STUDENTNAME:___________________________________________

Student ApplicAtion

ACADEMIC SECTION

pARt

13 www.ayusa.org



3A LANGUAGE SKILLS

1) Reading Comprehension:GivenanAmericannewspaperormagazinearticleofatleastfiveparagraphs,thestudent:

oExcellent Understandsandexplainsitsmeaningclearlyandcompletely.Studentunderstandsatleast9outofevery10words.

oGood Understandsmostofitsmeaning.Studentunderstands7-8outofevery10words.

oFair Understandsthebasicvocabularyandexplainsthebasicideaofthearticle.Studentunderstands5-6outofevery10words.

oPoor Understandsonlythesimplestwordsandcanexplainlittle,ornoneofthearticle’smeaning.Studentunderstands1-4outofevery10

words.

2) Writing:Whenaskedtowriteashortessaystatinganopinionabouthisorherschool,town,politicalvieworsportsinterests,thestudent:

oExcellent Writeswithnearfluencyusinglengthysentences,abstractterms,andstrongvocabulary.StudentusesEnglishgrammarratherthan

translatingthegrammarofthenativelanguageintoEnglish.

oGood Usesgoodvocabulary.Studentwriteslengthyandsensiblesentencesandsometimesusesirregulargrammar,butmeaningisclear.

oFair Canmakeonlysimplesentencesusinglimitedorbasicvocabulary.Studentusesextremelyirregulargrammar,butmeaningisclear.

oPoor Writesincomplete,shortorbasicsentences,usingonlylimitedvocabulary.Attimesitisdifficulttounderstandwhatthestudentmeans.

3) Speaking and Understanding Conversation:Afterengagingthestudentinatleast15minutesofactiveEnglishconversation,usingbothabstract

termsandidiomaticphrases,ratethestudent’sabilitytospeakandunderstandEnglishconversation.

o 10 StudentisfluentinEnglish.Studentisabletobothunderstandandconverse,usingsophisticatedvocabularyandclear,correctsentence

structure.Studenthasnotroublewithabstractsubjectsormostidioms.StudentthinksinEnglish.

o 9 Studentisnearlyfluentandusesnear-perfectsentencestructures.Studentcanunderstandandrespondtodifficult

questions.Englishlanguageknowledgeincludesabstractterms.Studentwillhavenoproblemscommunicating,

whenheorshearrivesintheU.S.

o 8 Englishresponsescomesomewhatnaturally.Studenthasaverygoodvocabularyandunderstandsalmosteverything.Studentcanre-

spondintelligently,however,needspractice.

o 7 Studentcanunderstandmostconversation.Speakingabilityisgood,butneedspractice.Studentcangobeyondbasicresponsesand

elaboratethoughts.Studentknowsmanywords,butneedstothinkbeforeresponding.

o 6 StudentunderstandsbasicEnglish.Vocabularyincludesmostcommonterms.Studentthinksquickly;however,itisevidentthatheor

sheistranslating.Studentgetslostwhenconversationinvolvesabstractterms.Studentmakesmistakes,butisunderstandable.Student

cancarryonabasicconversation.

o 5 Studentcanunderstandmuchmorethanheorshecancommunicate;buttriestoimprove.Studentcanrespondinsentenceformeven

ifgrammarandstructurearenotperfect.Studentisunderstandable.

o 4 StudentevidentlyunderstandsbasicEnglishsentencesandisabletorespond,evenifonlyinwordsorphrases.Grammarandsentence

constructionispoor,butunderstandable.

o 3 Studentunderstandswordsorphrases,butnotcompletesentences.Speakingabilityislimitedtoafewwordsorphrases.

o 2 Studentunderstandsafewwords,buthaslittleornoabilitytocommunicatebeyondafewwords.StudentmayevenrefusetouseEng-

lish.

o 1 StudentisunabletounderstandconversationandknowslittleornoEnglish.

STUDENTNAME:___________________________________________

Student ApplicAtion

ACADEMIC SECTION

pARt

14 www.ayusa.org



3B

STUDENTNAME:___________________________________________

ENGLISH TEACHER’S RECOMMENDATION

1)Howlonghaveyouknownthestudent?_______________________year(s)_______________________month(s)

2)HowlonghaveyouhadthestudentasanEnglishlanguagestudent?_______________________year(s)_______________________month(s)

3)HowmanyyearshasthestudentbeenstudyingEnglish,eitherinpublicorprivateschool?_______________________years

Please comment on the following:

4)Student’soverallprogressinEnglish:

5)Student’sEnglishlanguageabilities(oral/writtenperformance,motivation,strengths&weaknesses):

6)Student’scooperationwithclassroom/schoolpoliciesandexpectations:

7)HowisEnglishtaughtinthestudent’sclassroom(e.g.throughconversation,audiotapes,booksandwrittenmaterials,etc.)?

Teacher’sName(PleasePrint):______________________________________________________________Title:______________________________

Signature:___________________________________________________________________________________________________________________

Student ApplicAtion

ACADEMIC SECTION

pARt

15 www.ayusa.org



3C

STUDENTNAME:___________________________________________

SCHOOL RECOMMENDATION

1)Hasthestudentskippedorrepeatedayear?oYesoNoIfyes,pleaseexplainwhyandofferanassessmentonthestudent’sperformancesince

theskipped/repeatedyear.

2)Doesthestudenthaveahistoryofcontinuousorfrequentabsencesfromschool?oYesoNoIfyes,pleaseexplain.

3)Doesthestudenthaveanyspecialeducationalneeds(i.e.asaresultofdyslexia,wordblindness)?oYesoNoIfyes,pleaseexplainwhyandout-

lineanyspecialrequeststhatthestudentmayhave.

4)Hasthestudenthadanyadjustmentordisciplinaryproblemsatschoolorinthecommunity?oYesoNoIfyes,pleaseexplain.

5)Howmanytotalyearsofschooling,includingallprimaryandsecondaryeducation,doesthestudentplantocompleteprior to university or entrance

into the work force?________________

6)HowmanyofthoseyearswillthestudenthavecompletedbyAugust2012?________________

7)Bythestartoftheprogram,willthestudenthavegraduatedfromsecondaryschool(i.e.completedallschoolings/heplanstocompletepriortouniver-

sityoremployment)?oYesoNoIfyes,pleaseexplain.

SCHOOL OFFICIAL AGREEMENT

AlloftheinformationIhaveprovidedinthissectionoftheStudentApplicationistrueandaccurateandIhavenotwithheldanyinformation.

_______________________________________________________________________________________________________________________

SchoolOfficial’sSignature Date

Student ApplicAtion

HEALTH SECTION

pARt

16 www.ayusa.org



4A

STUDENTNAME:___________________________________________

HEALTH STATEMENT

Inthissection,pleasegivefullinformationincludingdatesanddetailsabouteverydisease,disorder,orimpairmentthestudenthashad.Includeextradescrip-tionsorstatementsifnecessaryonaseparatepieceofpaper.

1)Doesthestudenthaveorhass/hehadanyofthefollowing?

YES NO DATE YES NO DATEAllergies o o ________ LearningDifficulties o o ________Anorexia o o ________ LearningDisability o o ________Appendicitis o o ________ Malaria o o ________Asthma o o ________ Measles o o ________AttentionDeficitand/or o o ________ Mumps o o ________HyperactiveDisorder Parasites o o ________Bulimia o o ________ Pneumonia o o ________Cancer o o ________ Poliomyelitis o o ________ChickenPox o o ________ RheumaticFever o o ________Cough(Persistent) o o ________ Rubella(Germanmeasles) o o ________Depression o o ________ ScarletFever o o ________Diabetes o o ________ SeizureDisorder o o ________Dyslexia o o ________ Sleepwalking o o ________EatingDisorder o o ________ Smallpox o o ________Enuresis o o ________ Speechdifficulties o o ________Epilepsy o o ________ Tuberculosis o o ________Goiter(Struma) o o ________ TyphoidFever o o ________Headache(Persistent o o ________ Ulcer o o ________orMigraine) Vertigo,Dizziness o o ________HepatitisA,B,orC o o ________ WordBlindness o o ________Hernia o o ________

2)Ifyouanswered“Yes”toanyoftheabove,please give details and outcome for each condition. Note any continuing care required or write “none.”

3)Hasthestudentexperienceddisease,impairmentorabnormalityofanyofthefollowing?

YES NO DATE YES NO DATEAbdominalOrgans o o ________ Brain,NervousSystem o o ________Genito-UrinarySystem o o ________ Skin(Acne,etc.) o o ________ Bones,Joints o o ________ EarsorHearing o o ________HeartorBloodVessels o o ________ Tonsils,NoseorThroat o o ________Blood,EndocrineSystem o o ________ EyesorVision o o ________ Lungs,Respiratory o o ________ VaricoseVeins o o ________System

4)Ifyouanswered“Yes”toanyoftheabove,please give details and outcome for each condition. Note any continuing care required or write “none.”

Student ApplicAtion

HEALTH SECTION

pARt

17 www.ayusa.org



4B

STUDENTNAME:___________________________________________

HEALTH BASICS

1)Forhowlonghasthestudentbeenyourpatient?______________________

2)Height:_____________cm

3)Weight:_____________kilos

4)Pleaselistanymedicationorsupplements,eitherover-the-counter(doesnotrequireaprescription)orprescriptionthatthestudentiscurrentlytaking,evenifinfrequently.Forwhatreasonishe/shetakingthismedication?Howfrequently?Pleasegiveasmanydetailsaspossible,includingwhetherornotthestudentwillbringmedicationwithhim/hertotheUnitedStates.

MEDICATION PURPOSE FREQUENCYIS STUDENT REQUIRED TO TAKE THIS MEDICATION

WHILE ON THE PROGRAM?

WILL THE STUDENT BRING A SUFFICIENT SUPPLY TO LAST THE

ENTIRE DURATION OF THE PROGRAM?

oYesoNo oYesoNo

oYesoNo oYesoNo

oYesoNo oYesoNo

oYesoNo oYesoNo

5)Pleasecompletethefollowingophthalmicinformationonlyifthestudentwearsglassesorcontactlenses.

SPHERE CYLINDER AXIS PRISM BASE

(OD)OcularDexter

(OS)OcularSinister

Add:

BaseCurve:

Other:

Student ApplicAtion

HEALTH SECTION

pARt

18 www.ayusa.org



6)Pupillaryandkneereflexesnormal? oYesoNo

7)Hasthestudenteverbeenhospitalized?Ifyes,pleasegivedates,diagnosis,treatment,andoutcomedescriptionofeachillnessoraccident.

8)Doesthestudenthaveanypastorcurrentsymptomsofeatingdisorders,depression,nervousbreakdown,fatigue,nightmares,stammering,stuttering,

anxietyattacks,orothersimilarnervous,emotionalormentalconditions?Ifso,pleasedescribe.

9)Hasthestudenteverdisplayedsymptomsofdrugsoralcoholabuse?Ifyes,hasthestudenteverbeenhospitalizedorcounseledasaresult?

10)Willthepatientrequireanyorthodonticcareduringthecomingyear?Ifyes,pleasedescribefrequencyandtypeofcarerequired.

11)Arethereanyrestrictionsonthestudent’sparticipationinphysicaleducationand/orsportsactivities?Ifyes,pleaseexplain.

4B (continued)

STUDENTNAME:___________________________________________

Student ApplicAtion

HEALTH SECTION

pARt

19 www.ayusa.org



Allergicto Severity

Controllable

with

Medication?

Medication

Willthestudentbring

sufficientsupplyfor

theentiredurationof

program?

AN

IMA

LS

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

FOO

DS

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

DU

ST &

PO

LLEN

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

MED

ICA

TIO

NS

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

OTH

ER

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

oSevereoMedium

oMild

oYes

oNoName:

oOTC

oPrescription

oYes

oNo

4C

STUDENTNAME:___________________________________________

ALLERGY DETAILS

1)Isthereamedicalreasonwhythestudentcannotliveinahomewithapet?oYesoNoIfyes,pleaseexplain:

2)Willthestudentneedspecialmealstoaccommodateanallergy?oYesoNoIfyes,pleaseexplain:

3)Pleaselistanyallergiesthestudenthasandindicatetheseverityoftheallergy,ifitcanbecontrolledbymedication,andwhatmedicationthestudent

takesoriswillingtotakefortheallergywhilelivingintheU.S.

Student ApplicAtion

HEALTH SECTION

pARt

20 www.ayusa.org



4D

4E

STUDENTNAME:___________________________________________

IMMUNIZATION RECORD

VACCINE DATE EACH DOSE WAS GIVEN:

1st DAY/MO/YR 2ndDAY/MO/YR 3rdDAY/MO/YR 4thDAY/MO/YR 5thDAY/MO/YR

DTP (Diptheria, Tetanus, Pertussis) (5doses.Firstdosenotto

begivenbefore6weeksofage,4weeksbetweendoses1&2

and4&5,24weeksbetween3&4)

Additional Tetanus (1doseofadditionalTetanusisneededif

DTPwasnotwithinthelast5years)

Polio (4doses,firstdosenottobegivenbefore6weeksofage,

4weeksbetweendoses1&2and6weeksbetweendoes2&3

and3&4)

Measles (2doses,firstdosenottobegivenbefore12months

ofage,minimumof4weeksbetweendoses)

Rubella (2doses,firstdosenottobegivenbefore12monthsof

age,minimumof4weeksbetweendoses)

Mumps (2doses,firstdosenottobegivenbefore12monthsof

age,minimumof4weeksbetweendoses)

Hepatitis B (3doses,nominimumageforfirstdose,4weeks

betweendose1&2,and8weeksbetweendoses2&3)

Varicella (Chicken Pox)

Pleasecheckoneboxbelowandprovidedate.

oPreviouslyContracted/Date__________________

OR

oImmunization/Date__________________

Tuberculosis

Pleasecheckoneboxbelowandprovidedate.

oImmunization/Date__________________

OR

oNegativeTB/TineSkinTest/Date__________________

OR

oClearcopyofanegativeChestx-ray

CONCLUSION

1)Inconclusion,pleasegiveyouropinionofthegeneralstateofthestudent’shealth.

oExcellentoGoodoFairoPoor

•Ihavegivenathoroughphysicalexaminationandreviewedthemedicalhistoryofthecandidateandcertifythatallimportantmedicalinformation

hasbeenincludedandthattheaboveinformationistrueandaccurate.

•Iaffirmthatthepatientisstable,bothphysicallyandmentally,toparticipateinanexchangeprogramabroad.

________________________________________________________________________________________________________________________________

PhysicianName(PleasePrint) City Country

________________________________________________________________________________________________________________________________

OfficePhone Fax

________________________________________________________________________________________________________________________________

Physician’sSignature(Required) Date

AYUSA OVERSEAS PARTNER SECTION

Student ApplicAtion pARt

21 www.ayusa.org

1 52 4 6 7Student Parent Health Program

Agreements Photos

3Academic Overseas

Partner

5A

5B

STUDENTNAME:___________________________________________

PROGRAM INFORMATION

1)Program:oAcademicYearoFallSemester

2)ProgramYear:__________

3)Preferredairportofdeparturefromhomecountry:__________________________________

STUDENT INTERVIEW

1) _________________________________________________________________ 2) ____________________________

InterviewerName(PleasePrint) InterviewDate

3)Wastheinterviewatleastonehourinlength?oYes

4)Wasinterviewconductedinperson?oYes

5)WasinterviewconductedinEnglish?oYes

6)Pleasedescribethemostpredominantaspectsofthestudent’scharacter.

7)Whatarethestudent’shopesandexpectationsfortheprogram?

8)Howdoesthestudenthopetoachievetheseexpectations?



22 www.ayusa.org


Agreements Photos

3Academic Overseas

Partner

5B

STUDENTNAME:___________________________________________

9)Explainthathostfamiliesvolunteertosharetheirliveswithanexchangestudent.Whatdoesthestudentfeelwouldbeexpectedofhim/herwhileliv-

ingwithahostfamily?

10)Asfarasyoucantell,doesthestudenthaveanyspecialneedsthatmayinfluencethehostfamilyplacement?

11)Askthestudenttodescribehowhe/shehopestopersonallygrowfromthisexchangeexperience.

12)Askthestudentifhe/shehasanymedicalconcernsorphysical/healthneedsthatmayaffecthis/herexchange.Forexample,aneatingdisorder,diabe-

tes,orepilepsy.Pleasebediscretewhenaskingthesequestions.

(continued)



23 www.ayusa.org


Agreements Photos

3Academic Overseas

Partner

13)Discussexpectationsregardingcommunicationwithnaturalfamilyandfriends.Forreference,pleaseconsulttheAyusaParticipantHandbook.Tofully

adaptandbenefitfromtheirexperienceintheU.S,itisexpectedthatstudentswilllimittheircontactwithfriendsandfamilyathometoonephone

callore-mailperweek.Studentsareexpectedtoabidebyanyrestrictionsimposedbythehostfamilyregardingphoneandcomputeruse.Doyou

haveanyconcernsaboutwhatisexpectedofthestudent?

14)Discusscomputerandinternetuseexpectations.Internetaccessmaynotbeavailableinhostfamilyhomes.Ifinternetisavailable,studentsare

expectedtoabidebyhostfamilyrulesaswellasAyusaInternetSafetyRules,(p.21ParticipantHandbook).Ingeneral,studentsshouldlimitinternet

usetooccasionaleducationalresearchandweeklycontactwithfriendsandfamilyathome.Privateinformationandidentityshouldneverbeshared

online.Theyshouldthinkabouttheconsequencesbeforepostinganyinformationandimagesonline.Doyouhaveanyconcernsaboutthestudent

complyingwiththispolicy?

15)Discusstransportationoptionsthatareacceptablewhilethestudentisonprogram,andclarifythatdrivingisnotallowed.Doesthestudentunder-

standthisrule?

16 )Doesthestudenthaveanystronglikes/dislikes,phobias/fearsordietaryrestrictions?

5B

STUDENTNAME:___________________________________________

(continued)



24 www.ayusa.org


Agreements Photos

3Academic Overseas

Partner

5B

STUDENTNAME:___________________________________________

(continued)

17)Arethereanyaspectsofthestudentorthestudent’sdescriptionofhis/herparentsthatraiseconcernsforyouorthatyoufeelAyusashouldknow?

18)Whatdoesthestudentseeasthemostchallengingpartoffittingintoanewfamily?Discussthefactthatthestudentneedstoadaptandchangeto

fitintoahostfamily;itisnotuptothefamilytoadjusttothestudent.Describehowthelifestylemostlikelywillbeverydifferent,givingexamplesof

differencesinhome,food,andcommunities.

19)Pleasedescribeatimethestudentdemonstratedmaturityand/orflexibility.



25 www.ayusa.org


Agreements Photos

3Academic Overseas

Partner

20)Ayusastudentsarenotpermittedtoconverttoareligiondifferentfromtheirown,andhostfamiliesareinstructednottopressurestudentstoparticipate

inreligiousactivitiesorchangetheirbeliefs.However,attendingreligiousservicesand/oryouthgroupsareanimportantcommunityactivityformany

Americanfamilies.

a)Haveyoudiscussedwiththestudenttheimportanceofparticipatinginreligion-relatedactivitieswiththehostfamily? oYesoNo

b)Isthestudentwillingtoparticipateinreligion-relatedactivitieswiththehostfamily? oYesoNo

21)Discusshowthedefinitionofthe“traditionalAmericanfamily”ischangingandthestudentmustbewillingtobeplacedinanyofthebelowlivingar-

rangements(thisisnotatimetoexpresspreferencesbutinsteadtolearnaboutallplacementpossibilities):

•Asingleparentwithoneormorechildrenathome

•Ayoungcouplewithnochildren

•Anoldercouplewithnochildren

•Aremoteruralarea

a)Haveyoudiscussedallpossiblelivingarrangementswiththestudent?oYesoNo

22)PlacementPreferences(studentisfreetochooseorindicatepreferenceinthebelowlivingarrangements)afterdiscussingplacementpossibilities

above.

a)IsthestudentwillingtolivewithanotherexchangestudentinaDoublePlacement?oYesoNo(Pleasemakesurethismatcheswhatis

checkedintheProgramAgreementssection)

b)Isthestudentwillingtolivewithasingleadultwithnochildren?oYesoNo

23)Howwouldyoudescribethestudent’sspokenEnglishlanguageability?

24)Attheconclusionoftheinterview,howwouldyousummarizethisstudent?Whatmakesthisstudentspecialorunique?Pleasebeasdetailedas

possible.Thisisachanceforyoutosetthisstudentapartfromothers.

5B

STUDENTNAME:___________________________________________

(continued)



26 www.ayusa.org


Agreements Photos

3Academic Overseas

Partner

5C

STUDENTNAME:___________________________________________Pleaserefertoinstructionsonpage2ofapplicationtocompletethischart.

GRADE CONVERSION CHART

Academic Year 2008-09Gradelevel_________




Subjects FINALGRADES

U.S.GRADE FINALGRADES

U.S.GRADE FINAL GRADES

U.S.GRADE FINALGRADES

U.S.GRADE

1)RecommendedU.S.GradeLevel:__________

PLEASE NOTE: Gradelevelsaredeterminedattheschool’sdiscretion.Wecannotguarantee12thgradeplacementorgraduation.

2)GraduatedStatus:Atthestartoftheprogram,thisstudentwillhavecompleted__________of__________yearsofprimaryandsecondaryschool.

3)Willstudenthavegraduatedatthestartoftheprogram?oYesoNo

4) SLEP TEST administered by Ayusa agent or English Teacher

(Pleaseinsertthestudent’sSLEPtestscoresheetinthissection.)

SCALEDSCORE:__________________________DATEOFTEST:__________________________

Ayusa Overseas Partner Agreement

AlloftheinformationIhaveprovidedinthissectionoftheStudentApplicationistrueandaccurateandIhavenotwithheldany

information.

_________________________________________________________________________________________________________________________

AyusaOverseasPartnerSignature Date

GradingScale

____________=A

____________=B

____________=C

____________=D

____________=F

3Academic

1 52 4 7Student Parent Health

6Program


27 www.ayusa.org

THIS PAGE INTENTIONALLY LEFT BLANK

PROGRAM AGREEMENTS

PART

28 www.ayusa.org

Student ApplicAtion 3Academic

1 52 4 7Student parent Health

6Program


For 2013-2014 Participants

Ayusa International Program AgreementAyusaInternational,itsagents,affiliates,officers,directors,staff,regionalandlocalrepresentatives(collectively“Ayusa”)andtheundersignedparent(s)orlegalguardian(s) (“Parents”)andstudent(“Student”),understandandagreetothetermsandconditionsstatedinthisProgramAgreement(“Agreement”) relatingtoStudent’sparticipationinAyusa’sstudentexchangeprogram(“Program”).ParentsandStudentarereferredtocollectivelyastheParticipants(“Participants”).AdultsandtheirresidentchildrenwhovolunteertohostastudentfortheProgramtermarereferredtoastheHostFamily(“HostFam-ily”).TheUnitedStates,wheretheStudent’sprogramistakingplace,willbereferredtoastheHostCountry(“HostCountry”).

Selection Standards:AllAyusaStudentsmustmeettheselectionstandardsforexchangevisitorsestablishedbytheU.S.DepartmentofState(22CFR62)andtheCouncilonStandardsforInternationalEducationalTravel(CSIET)whichincludebutarenotlimitedtoEnglishproficiency,bonafidestudentstatus,andacademicpreparation.Ayusadoesnotrecruitorplacestudentsonthebasisoftheirathleticability,doesnotguaranteeparticipationinschoolsportsordriver’seducation,nordoesAyusainanywayguaranteestudentswillgraduateorreceiveadiplomafromtheirU.S.highschool.

Student Application and Admission:AyusaconsidersmanycriteriaindeterminingwhethertoadmittheStudentintotheProgramincludingbutnotlimitedtoaStudent’sapplicationpacket,academicbackground,highschooltranscript,age,educationlevel,physicalandmentalhealth,references,essay,andpersonalinterview.AyusaacceptsStudentswiththeexpectationthattheinformationcontainedintheStudentApplicationiscompleteandtrue.AnybreachofoneoftheStatementsofTruthwithintheStudentApplicationcouldprovidegroundsforconsiderationofdismissalfromtheprogramatanytime,priororduringtheprogram.AyusahasthesolediscretiontodeterminewhethertheStudentwillbeadmittedintotheProgramandsuchdeterminationisfinal.

Important: IfanychangesoccuroraremadetotheinformationcontainedintheHealthSection(suchasachangeinStudent’smedication),AyusaAgentmustinformAyusainwriting.

Placement and Diversity:WhileAyusamakeseveryefforttotakeindividualneedsintoconsiderationinplacingStudentswithHostFamilies,AyusamaybeunabletoaccommodateallpreferencesandcharacteristicsoftheStudentintheplacementprocess.Ayusaexpectseachstudenttoadjusttothefamilyselectedforhimorher,regardlessoftheirethnicityorthesizeofthecommunity.Itisimportanttounderstandthatthereisno“perfect”HostFamilyandcommunity.StudentsmustaccepttheHostFamilyandcommunityAyusaselectsandmakeeveryefforttobecomeamemberoftheHostFamilyandcom-munityandparticipatesuccessfullyintheacademichighschoolprogram.

Dissimilarities or Differences in the Host Country: InadditiontolearningthelanguageoftheHostCountry,theStudentisexpectedtomakeeveryefforttoadapttothecultureandlifestyleoftheHostFamilyandtheHostCountry.Theremaybesignificantcultural,economic,andlifestyledifferencesbetweentheStudent’shomecountryandHostCountryincludingthoseinhealthcareservices,livingconditions,transportationsystems,educationalsystems,criminaljustice,civilliberties,customs,valuesandacceptablebehaviorwithregardstoageandgender.LivingconditionsmayalsovarybetweenHostFamiliesevenwithinthesamecommunity.ParticipantsmustbeawareofandacceptthesedifferencesaspartoftheProgram,andaccepttherisksassociatedwithtravelingandlivinginanothercountry.TheStudent’slevelofmaturitymustbeadequatetorecognizeandcopewiththesedifferencesandchallenges. ParentsmusttakeresponsibilitytoeducateandpreparetheStudentfortheinherentrisksassociatedwithforeigntravelandlivingabroad.AyusaAgentswillregularlymonitortheStudent’sprogressandareavailableinpersonorbytelephonetoprovideregularongoingsupportandemergencyassistanceduringtheProgram.HoweverAyusacannotanddoesnotprovideconstantdirectsupervisionoftheStudent.TheStudentmustberesponsiblefortakingtheinitiativetocommunicatewithAyusaandseekhelpassoonasshe/heneedsassistance. AsaconditionofacceptanceintotheProgram,theParticipantsagreeandholdAyusaharmlessforallinjuriesand/ordamagesincurredduringtheStu-dent’sparticipationintheProgramresultingfromanyrisksassociatedwithinternationaltravelandlivingabroad,andanynegligenceand/orintentionalactscausedbyanythirdparty,includingbutnotlimitedtoanymember,guest,employeeoragentoftheHostFamilyorotherpersonintheHostCountry.

Living Expenses:ParentsagreetoprovidetheStudentwithasufficientamountofspendingmoneytocoverpersonalexpensesandincidentalsduringtheProgramsoasnottobeaburdenontheHostFamily.AyusarecommendsUS$200permonth.StudentsmustreimbursetheHostFamilyforextraordi-naryexpensessuchaspersonaltelephonecalls,medicalbills,textbooks,schoolactivityfees,ordamagesthatmayoccur.

Financial Responsibility:Werecommendthatstudentsnotopenjointsavings/checkingaccounts/cellphoneagreementsorengageinanyotherfinancialagreementswiththeirHostFamilies.Ayusaisnotresponsibleforfinancialrestitutiontostudentsorthenaturalparentsresultingfromtheseagreements.

PROGRAM AGREEMENTS

PART

29 www.ayusa.org



6Program


Ayusa Program Rules And PoliciesFor 2013-2014 Participants

AspartoftheAyusaprogramapplicationprocess,studentsandtheirnaturalparentssignanagreementtoabidebytheAyusaprogramrules.Theserulesaredesignedtoprotectourstudents,hostfamilies,andschools,andprovidethegeneralframeworkforasuccessfulprogramexperience.

TheAyusaRulesaresummarizedasfollows:

Rule 1: Host Family Regulations

Studentsmustobeyhostfamilyregulationsincluding,butnotlimitedto,rulesregardingcurfew,householdchores,datingandsexualactivity,contactwithhome,andcomputerandphoneprivileges(includingpersonallaptopsandcellphones).Studentsareresponsibleforcoveringthecostofalllong-distanceandinternationaltelephonecallsastheyincurthem.Studentsmaynothaveguestsinthehostfamily’shomewithouttheirhostfamily’sconsentandsupervision.

Rule 2: Academic Life

Ayusaisanacademicprogram.StudentsareresponsibleforattendingschoolandachievingaCorbettergradeineveryclass.Theymustfollowallaca-demicandbehavioralrequirementsasdefinedbytheirhighschoolorAyusa.Iftheschooladministrationdeterminesthatastudentisnolongerwelcometoattendduetobehavioraloracademicproblems,thestudentmaybedismissedfromtheAyusaprogram.

Ayusadoesnotinanywayguaranteethatstudentsmayenrollintwelfthgradeclasses,graduate,orreceiveadiplomafromaU.S.highschool.Studentsmustacceptandobeytheirschool’spolicies.

Rule 3: Local, State and National Laws

Studentsaresubjecttotheauthorityandlawsoftheirhostcountryandmustobeyallnational,state,andlocallawsandregulations.Studentsmustusetheirbestjudgmentandlearntheselaws.Ignoranceofthelawisnotconsideredalegaldefenseforbreakingit.Exchangestudentsarenotexemptfromlegalprosecution.ParticipantsagreetoholdAyusablamelessforanyorallconsequencesthatmayresultfromastudentbreakingthelawoftheland.BreakingthelawisgroundsfordismissalfromtheAyusaprogram.

Rule 4: Drugs

Theuseorpossessionofnon-prescriptiondrugsorcontrolledsubstancesisillegal.Studentsmayonlytakemedicationsprescribedbytheirdoctorormedicinescommerciallyavailableinthehostcountry.Somemedicationsthatarecommerciallyavailableinothercountriesrequireadoctor’sprescriptionintheUnitedStates.UseofillegaldrugsisgroundsfordismissalfromtheAyusaprogram.ExchangestudentsarrestedfordruguseorpossessionfacethesamepenaltiesascitizensoftheUnitedStates,includingmandatoryfinesorprisonterms,andwillbeimmediatelydismissedfromtheAyusaprogram.

Rule 5: Drinking and Smoking

Studentsmaynotdrinkorpurchasealcoholicbeverages,includingbeerandwine.TheminimumdrinkingageintheUnitedStatesis21years.Arrestandexpensivefinesmayresultfromviolatingthislaw,anditisgroundsforimmediatedismissalfromtheAyusaprogram.Studentsarenotallowedtosmokenicotine(cigarettes,cigars,chewingtobacco,etc.)andwillfaceAyusadisciplinaryproceduresiftheyviolatethisrule.

Rule 6: Driving

Studentsmayonlyparticipateinadriver’seducationprogramofferedbytheirhighschool.Theyarenotguaranteedanopportunitytoobtainadriver’slicense.Studentsmaynotdrivemotorvehicles,exceptduringparticipationinaformaldriver’seducationprogramattheirhighschool,becausestudents’insurancedoesnotcovertheseactivities.Thisbanappliestofour-wheelers,jet-skis,tractors,andanyothermotorizedvehicle.Studentsmayonlypartici-pateinschoolsponsoreddriver’seducationwiththepermissionofthelocalschool,naturalparents,hostparents,andAyusa.Studentsarenotallowedtobepassengersonmotorcycles,motorbikes,orscooters.Theyarenotallowedtopurchaseorownanymotorvehicle.

Rule 7: Life-Changing Events

Ayusastudentsmaynotinitiateany“life-changing”decisions,events,oractionswhileintheprogram.Thisincludeschangingreligion(thoughastudentmayexplorethetenetsofanyreligion),pregnancy,andmarriage.StudentsareexpectedtorefrainfromsexualactivitywhileintheAyusaprogram.Stu-dentsmaynotaltertheirbody(tattoos,bodypiercings,etc.)inanywaywhileintheprogram,eveniftheyhavepermissionfromtheirnaturalparents.

Regardingreligion:Hostfamiliesshouldunderstandthatstudentsarenotrequiredtoattendanyreligiousservices.However,inthespiritoflearningabouttheirhostfamily’svaluesandlifestyle,Ayusaencouragesstudentstoattendreligiousservicesoractivitiesiftheyareanintegralpartofthefamily’slife.Ifstudentsareuncomfortablewiththereligiouscontentofservicesoractivities,theyarenotrequiredtoparticipate. Studentsmaybedismissedfromtheprogramiftheysufferfromalife-threateningmedicalcondition,suchascancer,depression,oraneatingdisorder.

PROGRAM AGREEMENTS

PART

30 www.ayusa.org



6Program


Rule 8: Travel

Forsafetyandsecurityreasons,Ayusaneedstoknowthewhereaboutsofstudentsatalltimes.Studentsareexpectedtocomplywiththefollowingrulesandconditionsregardinganytravel.

·AllstudentovernighttravelawayfromthehostcommunityandwithoutthehostfamilymustbeapprovedbyAyusaandthestudent’snaturalparents.StudentsareresponsibleforcompletinganAyusaRequestforStudentTravelFormandcommunicatingdetailstotheirlocalAyusarepresentativeatleast14daysbeforeproposedtraveldate.

·StudentsmustobtaintravelpermissionfromAyusafortripswiththeirhostfamilythatincludemorethanthreeovernightstays.NaturalparentapprovalisrequiredinadditionforhostfamilytripsthatinvolveleavingU.S.territory.

·Foralltripsthatinvolvelessthanthreeovernightstays,studentsareresponsibleforinformingtheirCommunityRepresentativeinadvanceandmustprovidecontactinformationwheretheycanbereachedwhiletraveling.

·Flightsandaccommodationsshouldnotbepurchasedpriortoobtainingapprovalfortravel.Studentsandnaturalfamiliesarefinanciallyresponsibleforanytripsthatmustbecancelledorrescheduledduetolackoftravelpermission.

·AllstudenttravelmustoccurafterJanuary15thandshouldbelimitedtoweekendsandschoolvacationperiods.Exceptionsmaybemadefortripswiththehostfamily,andforschoolorAyusasponsoredtripsincludingBeloTours.Inorderforstudentstobepermittedtomissschoolinthecontextoftravel,his/herschoolandAyusamustgrantapproval.

·Studentsmaynottravelindependently;totravel,astudentmustbeaccompaniedbyaresponsibleadult(25yearsorolder)thatisapprovedbyAyusa.ExceptionsmayapplyforflightstoandfromAyusasponsoredevents.

·Studentsmaynotvisittheirhomecountryduringtheprogram.·EducationaltravelorsightseeingtoursthatarenotwiththehostfamilyorsponsoredbytheschoolorAyusa,mustbebookedthroughBeloTours,whichisapre-authorizedAyusapartnertourcompany.

·Inordertotravel,astudentmustbein“goodstanding”withAyusa.Studentsarenotconsideredin“goodstanding”iftheyareonwarningorprobation,oriftheirbehaviorindicatesthattheycannotbetrustedtoconductthemselvesinaresponsible,safe,andmaturemannerwhiletraveling.Forstudentswhowereplacedonwarningatanearliertimeintheprogram,travelpermissionmaybegrantedatthediscretionoftheRegionalManagerifsignificantimprovementhasbeenmadeonthepartofthestudent.

Pleasenote:TheAyusaTravelPolicygoesintoeffectthemomentwhenstudentsentertheUnitedStates.

Rule 9: Visits To and From Friends and Family

Visitsfromnaturalparentsandfriendsfromthestudent’shomecountry(andto/fromrelativesandfriendsintheU.S.)canbeextremelydetrimentaltothestudent’sadjustmentprocessandlanguagelearning.Therefore,visitsfromnaturalparents,extendedfamily,orfriendsarenotauthorizedbyAyusauntiltheendoftheprogram.Additionally,anytravelthatastudentundertakeswithhisorhernaturalparentsmusttakeplaceafterthestudentcom-pletestheprograminaccordancewithAyusaTravelandProgramReleasePolicies(rule8and10).ViolationofthisruleisgroundsfordismissalfromtheAyusaprogram.

Rule 10: Returning Home/Program Release

TheAyusaprogramfollowstheU.S.academiccalendar.Studentsareexpectedtoleavetheirhostcommunitiesandreturntotheirhomecountriesnomorethantwoweeksaftertheprogramenddate,whichisthelastdayofschool.

IfastudentwishestoremainintheU.S.afterthisdatetoundertakepersonaltravel,heorshemustcompleteandsubmitanAyusaProgramReleaseform,whichmustbesignedbythenaturalparentsandapprovedbytheAyusaRegionalManager.Aftertheprogramreleasedate,Ayusaandthehostfamilyarenolongerresponsibleforthestudent,andallbenefitsandservicesassociatedwiththeprogramwillnolongerbeavailable.

Studentsmustcompletetheirprogramtobeeligibleforprogramrelease.Studentswhohavebeendismissedorwithdrawnfromtheprogrammustim-mediatelyreturntotheirhomecountries.TheymaynotremainintheU.S.forpersonaltravel.

Thefollowingrequirementsapplyforprogramrelease: ·Thestudentwillbeinthecareandsupervisionofanadultovertheageof25forthedurationofthestayintheU.S.·Thestudent’snaturalparents/guardiansassumefullresponsibilityforanyexpensesrelatedtothestudent’sprolongedstayintheU.S.,includingfeesforaccommodations,travel,andflightchanges.

·Duringtheprogramreleaseperiod,thestudentwillupholdallJ1visarulesandregulationssetforthbytheU.S.DepartmentofState,includingthere-quirementformedicalinsurancecoverageforthedurationofthestudent’sstayintheU.S.

AnyviolationoftheAyusaprogramreleasepolicyandexpectationsmayimpactastudent’spermanentimmigrationrecordandfutureopportunitiestoentertheU.S.

PROGRAM AGREEMENTS

PART

31 www.ayusa.org



6Program


Insurance:AllstudentsarerequiredtohaveinsuranceineffectforthedurationoftheprogramcoveringsicknessandaccidenttostandardsestablishedbytheU.S.DepartmentofState.Policiesmaynotcoverpre-existingconditions,injuriesresultingfromdrivingmotorizedvehicles(exceptaspartofasuperviseddriver’seducationprogram),certaincategoriesofsportsinjuries,injuriesresultingfromthecommissionofacrime,self-inflictedinjuries,orinjuriessustainedfromparticipationinhigh-risk(extreme)sports.Participantsagreetofamiliarizethemselveswiththecoverage,exclusionsandlimita-tionsoftheirinsurancepolicyandtoconsultwiththeirAyusaagentandtheirinsuranceproviderbeforehandtodeterminewhatactivitiesareexcludedfromcoverage.Anyexclusionsorlimitationsoftheinsurancewillbethefinancialresponsibilityofthenaturalparents,nottheHostFamily,Ayusaover-seaspartner,orAyusaInternational.

Health Care Treatment: AyusawillnormallyconsultwithParentsbeforeauthorizinganymedicalcareforastudent.However,asituationrequiringim-mediateattentioncouldconceivablyoccur.InsuchacasetheParentsconsentandauthorizeAyusaoradultHostFamilymembertoobtainwithoutobliga-tion,andattheirdiscretion,anynecessarymedical,dental,surgical,psychological,psychiatricorhospitalcare,prescribedbyahealthcareauthority,fortheimmediatewelfareoftheStudent.TheParentsauthorizethehealthcareprovidertoreleasetheStudenttoAyusa,oradultHostFamilymemberandtoreleaseallhealthcarerecordsrelatingtotheStudenttoAyusa.

Legal Proceeding:ParticipantsconsentandauthorizeAyusatopursueordefendanylegalproceedingregardingtheStudentduringtheProgram,coststobereimbursedbyParent(s).However,AyusaoranyadultHostFamilymemberisnotobligatedtopursueordefendanysuchlegalactionorproceed-ings.TheParticipantsauthorizeanycourt,lawenforcementagency,oranyothergovernmentagencytoreleasetheStudenttoAyusaintheeventthattheStudentisdetainedorheldbyanysuchentity.

Use of Student’s Name and Likeness:ParticipantsconsentandauthorizeAyusatousetheStudent’sname,photograph,fileorvideolikenessofStudentoranycommentsorstatementsofStudentinmaterialsorpublicationstopromotetheProgram. End of Program and Ayusa Release: AstheStudent’sprogramsponsor,AyusamustauthorizereleasefromProgramforanytravelintheU.S.aftertheendoftheAyusaprogram.OnlyStudentswhoareingoodstandingwiththeProgramareeligibletorequestanAyusaRelease.IfStudenthasreceivedaprobationletterduringtheprogram,theStudentisnoteligibleforanAyusaRelease.Ayusa’sdecisiononreleaseisfinal.AnytravelthatisunauthorizedwillbeconsideredasabandonmentoftheprogramandwillbenotedintheStudent’sSEVISimmigrationrecordwhichmayimpacttheStudent’sabilitytore-entertheUnitedStatesinthefuture.NeitherAyusastaffnortheHostFamilywillberesponsibleforaStudentwhoremainsillegallyintheUnitedStatesaftertheendoftheProgram.Inaddition,theStudentwillnotbecoveredbyanyinsurancepolicyprovidedthroughAyusaaftertheEndoftheProgram.ParticipantsexpresslyreleaseAyusa,itsrepresentativeorganizations,andtheHostFamilyfromallliability,injury,damagesorclaimsincurredaftertheterminationoftheProgram. Problem Notification and Resolution:AyusaprovidesongoingsupportofallStudents;howeverStudentscannotbecontinuallysupervisedorcontrolledbyAyusa.ItistheresponsibilityoftheStudenttoadviseAyusaofanysignificantproblems,suchasconcernsabouthealth,safety,adjustmentproblemswithschool,language,cultureorissuesinvolvingtheHostFamily.AyusawillmakeeveryefforttointerveneandresolvetheseproblemstohelptheStudentsuccessfullycompletetheProgram.Inthiseffort,Ayusamay,initssolediscretion,seekareplacementHostFamily,ifpossiblewithinthesamecommunity.However,iftheStudentdoesnotmakeasubstantialgoodfaitheffortoriftheStudentviolatesanytermsofthisAgreement,Ayusamay,initssoleandabsolutediscretion,terminatetheStudent’sparticipationintheProgramandimmediatelyrepatriatetheStudenttothehomecountry.

Agreement between Students and Originating Exchange Organization:Ayusahasacontractualagreementwithitsoverseasrepresentativesor“AyusaAgent”,tooperateallprogramsinfullcompliancewithU.S.DepartmentofStateregulationsgoverningtheExchangeVisitorsProgram22CFR62 Part514 (March19,1993)andthestandardsoftheCouncilonStandardsforInternationalEducationalTravel(CSIET).Beyondthetermsofthiscontract,ParticipantunderstandsthatAyusaisnotapartytoanyagreementbetweentheStudentandtheOriginatingStudentExchangeOrganization(“Originat-ingExchangeOrganization”)throughwhichtheyappliedfortheAyusaProgramintheirhomecountry.ParticipantsacknowledgethatalldisputesorclaimsarisingoutofanydisagreementwiththeOriginatingExchangeOrganizationshallberesolveddirectlywiththeOriginatingExchangeOrganization.

General Release and Hold Harmless Provisions:AsaconditionoftheStudent’sparticipationintheProgram,theParticipantagreestoreleaseandholdAyusaharmlessforinjury,loss,delay,oranydamageandexpenseincurredbytheStudentdueto:(i)anyincidentbeyondAyusa‘sreasonablecontrol,in-cluding,withoutlimitation,actsofGod,crimesofviolence,actsofwar,orgovernmentactionsandrestrictions;(ii)anyeventsdirectlyorindirectlycausedbyintentionalornegligentactsoromissionsbyanythirdparty,includingbutnotlimitedtoanymember,guest,employeeoragentoftheHostFamilyoranyotherpersonsinthehostcountry;(iii)risksassociatedwithforeigntravelandlivingabroad,includingbutnotlimitedtorisksassociatedwithhealthcare,sanitation,transportation,crime,justice,legalsystems,customs,andvalues;(iv)anydifferencesinthelivingconditionsandstandardsbetweentheStudent’shomeandhomecountryandthehosthomeandHostCountry;and(v)anyactoromissionoftheOriginatingExchangeOrganization.

PROGRAM AGREEMENTS

PART

32 www.ayusa.org



6Program


Indemnification:AsafurtherconditionoftheStudent’sparticipationintheProgram,theParticipantagreestoindemnifyandholdAyusaharmlessfromanyliabilityorexpense,includingcourtcostsandattorney’sfees,resultingfromanyinjury,lossoranyotherdamageorexpensecausedbytheStudentduringhis/herparticipationintheProgram.

Arbitration and Venue:ThisagreementshallbedeemedtohavebeenmadeintheStateofCalifornia,USAanditsvalidity,construction,breach,perfor-manceandinterpretationshallbegovernedbythelawsoftheStateofCalifornia,USA.ThepartiestotheAgreementacknowledgeandagreethatanydisputeorclaimarisingoutofthisAgreement,anyresultingorrelatedtransaction,ortherelationshipoftheparties,shallbedecidedbyneutral,exclusiveandbindingarbitrationinSanFranciscoCounty,California,USA.ThearbitrationshallbeconductedbeforeJAMS/Endispute,Inc.Eitherpartymayappeartelephonicallyatthearbitrationhearing.TheawardofthearbitratormaybeenforcedinanycourtofcompetentjurisdictionlocatedintheStateofCalifor-nia,USA.Intheeventthatthearbitrationclauseisdeemedvoidorinapplicable,eachpartyexpresslyconsentstoandsubmitstothepersonaljurisdictionofthefederalorstatecourt(s)ofSanFranciscoCounty,California,USA.Inanyaction,includingarbitration,broughtforbreachofthisAgreement,theprevailingpartyshallbeentitledtorecoverreasonableattorney’sfeesandcosts,including,butnotlimitedto,thecostsofarbitration. Ratification of Contract:IntheeventtheStudentisundertheageof18atthetimeofexecutionofthisAgreement,andtheStudentattains18yearsofagewhileparticipatingintheProgram,theStudentagreesthatcontinuedparticipationintheProgramafterhe/sheattains18isdeemedaratificationandadoptionofallthetermsandconditionsofthisAgreement. Ayusa Program Agreement Controls: WherethereareanydifferencesbetweenthisAgreementandanyotherprogrammaterials,theAgreementshallcontrol.Ayusacannotbelegallyboundorcommittedbyanypersonotherthanadulyauthorizedrepresentative.PartiesarerequiredtofollowthisAgree-mentandcannotvaryfromitsterms. Modification:ThisAgreementshallnotbemodifiedexceptbyawrittenagreementthatisexecutedbyallpartieshereto. Severability: Intheeventanyclause,sentence,termorprovisionofthisAgreementshallbeheldbyanycourtofcompetentjurisdictiontobeillegal,invalidorunenforceableforanyreason,theremainingportionsofthisAgreementshallremaininfullforceandeffect.

PROGRAM AGREEMENTS

PART

33 www.ayusa.org



6Program


3) Double Placement Agreement

Doubleplacementsarewonderfulopportunitiesforexchangestudentsbecausetheyallowthestudenttosharesimilarexperienceswithanotherex-

changestudent.U.S.DepartmentofStateRegulationsrequirepriorconsentfromthestudentsandtheirnaturalparentsifstudentsaredoubleplaced.Itis

thechoiceoftheStudentandParentswhetherornottobeplacedinaDoublePlacement.Pleasecheckoneoftheboxesandsign.

oAsaParticipant,IamopentobeingplacedinadoubleplacementwithanotherAyusastudent.Iagree,inadvance,tothisdouble

placement.

oAsaParticipant,IamnotwillingtobeplacedinadoubleplacementwithanotherAyusastudent.

_______________________________________________________________________________________________________________________

StudentName(Printed) Signature Date

_______________________________________________________________________________________________________________________

Mother/GuardianName(Printed) Signature Date

_______________________________________________________________________________________________________________________

Father/GuardianName(Printed) Signature Date

1) Signatures:WehavereadandfullyunderstandtheprogrammaterialsandagreetoadheretotheAyusaRulesforStudentsandtheAyusaProgram

AgreementandConsentAgreements.Weaffirmthatalltheinformationprovidedinthestudentapplicationistrueandaccurateandthatwehavenot

withheldanyinformation.Weunderstandthatanyfailuretodiscloseinformationthataffectsthesafetyandwellbeingofthestudent,asdeterminedby

Ayusa,maybegroundsforimmediatedismissal.

_______________________________________________________________________________________________________________________

AyusaOverseasPartnerRepresentativeName(Printed) Signature Date

_______________________________________________________________________________________________________________________

StudentName(Printed) Signature Date

_______________________________________________________________________________________________________________________

Mother/GuardianName(Printed) Signature Date

_______________________________________________________________________________________________________________________

Father/GuardianName(Printed) Signature Date

2) Smoking/Drinking Agreements

IagreenottodrinkontheAyusaprogram.Student signature: ______________________________________________________________________________

IagreenottosmokeontheAyusaprogram.Student signature: ____________________________________________________________________________

PHOTO ALBUM

PART

34 www.ayusa.org


1 52 4 7Student parent Health photos

6program

Agreementsoverseas partner

To be Completed by the Student

1)Minimumof4photographs

Instructions:Select4-8picturesofyou,yourfamilyandfriendsintheplacesyouliveorfrequentlyvisit,doingthethingsyouusuallydoorliketodo.

Eitherprintthemoutonacolorprinterorpastethemonapieceofpaper.Onthepaper,writeanexplanationabouteachpicture,capturingthetrue

spiritofyourdailylife.Thealbumwillgiveyourhostfamilyanunderstandingofyourfamily,homeandlifestyle.Pleaserepresentyourselfpositively

andfeelfreetoexpressyourcreativity.

2)YouarewelcometoincludeaCDwith4-8photosineithera.jpgor.pdffileformat.

3) 2SMILINGhead-shotphotos,4.5x3.5centimeters,inanenvelope.

Instructions:BeneatlygroomedandbesuretoSMILEforthephotographsevenifitmakesyoufeelalittlesilly.Thesephotosofyouwillbethefirstim-

agesthehostfamilyandschoolofficialswillreceive.

PHOTO ALBUM

PART

35 www.ayusa.org


1 52 4 7Student parent Health photos

6program

Agreementsoverseas partner

PLEASE USE THIS SPACE FOR ADDITIONAL PHOTOS

36

APPLICATION CHECKLISTSTUDENT ID#_________________ STUDENT NAME: _______________________________________ AGE_______ GENDER_______ PARTNER______________

COMMENTS 1STREVIEW 2NDREVIEW

Part 1: Student Section

2smilinghead-shotphotos

BiographicalInformation

AgeEligibility

GettingtoKnowYou

ShortEssay

HostFamily/CommunityPlacementAgreement

StudentLetter

BirthCertificatecopy/Passportcopy

Part 2: Parent Section

FamilyInformation

InCaseofEmergency

MedicalReleaseAuthorization

ParentLetter

ConsenttoTakeDriver’sTraining oYesoNo

PrivateHighSchoolOption oYesoNo

PermissiontoParticipate

HostFamily/CommunityPlacementAgreement

Part 3: Academic Section

EnglishTeacher’sRecommendation

SchoolRecommendation

SchoolOfficialAgreement

Part 4: Health Section

HealthStatement

HealthBasics

AllergyDetails

ImmunizationRecord

Conclusion

PhysicianAgreement

Part 5: Ayusa Agent Section

InterviewQuestions

GradeConversionChart

AyusaAgentAgreement

SLEPTest Score:

3YearsofOfficialTranscripts

Part 6: Program Agreements

RequiredSignatures

Part 7: Photo Album

4-8Photos

For Internal Use Only

#1Reviewby: UploadPhoto,Essay,andApplication: #2Reviewby:

Documents

2013-2014 Student Application - Ayusa Student Application... · The student should demonstrate a strong desire to integrate into the host family lifestyle. All Ayusa host families