Student Application 2008

8/11/2019 Student Application 2008

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JanuaryAugust

WORLD EXPERIENCE

Teenage Student Exchange

2440 S. Hacienda Blvd., Suite 116

Hacienda Heights, California 91745 USA

[email protected]

RETURN THIS APPLICATION TO:

Please attach

5 RECENT and SMILING photos

in COLOR

PLEASE PRINT IN ENGLISH AND IN BLACK INK

List past or present organizational memberships, positions held, approximate dates:

Organizationsand Clubs(school,

church, farm,civic, sports,social, etc.)

Music and Artistic Interests

WE 8

S L E

(Poor) (Average) (Good) (Excellent)

Sports and Athletics (Poor) (Average) (Good) (Excellent)

Organization Names Posi tions Held ( if any) Yr. to Yr.

Last Name

Eye Color Hair Color SexHeight Weight

One Semester

Program Choice

to

Program Year

Departure

1.

2.

3.

Country Choices: List 3 countries in the order ofyour preference. Do not list states or cities.

Application Date

month day ye

Country

Middle NameFirst Name

Date ofBirth

Academic Year

to

to

to

to

to

to

to

Sport Position Played Level of Skill

List hobbies (exclude sports) and other leisure-time activitiyou enjoy and rate your participation:

(F) Frequent (O) Occasional (P) Periodic F O

month day year

1

STUDENT APPLICATION

Level of Skill

The information in this application will be used to help place you with your hostfamily. Please answer all the questions and rate yourself using the provided scale

Nickname

For Applicants To The USA Only:

Please describe any travel to other countries (including othexchange programs). Where and when did you travel?

Have you previously visited the USA?

If yes, which visa(s) did you use to enter the USA? Pleascheck all that apply:

Yes N

B1/B2 (Tourist) F1 or J1 (Student)

Other:


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List languages other than your native language (P) Poor (F) Fair (G) Good (E) Excellent

EDUCATIONAL BACKGROUND

WE 8

A private school?

A public school?

All applicants must attach school transcripts from the last two years. A transcript from your current year must be brought with you when you arrive in your host coun

Type of course being studied: Total number of students inyour school:

School Currently Attending

Street Address/Route or Box Number

City

State/Providence

Area Code Phone Number

Country Postal Zone

County/District

Academic

Vocational

Commercial

Other (specify):

month day yearSchool year ends__________________ Current Grade Average (GPA)

Grade level to be completed by end of current school year?

2

Ability tounderstand

conversationSpeaking AbilityWriting AbilityReading Ability

LanguageYears oftraining Where learned

P F G E P F G E P F G E P F G E

LANGUAGE ABILITY

Expected date of high school graduation ___________________

month day year Email Address and/or Website

Participation in the World Experience program is primarilyfor the purpose of cultural exchange.

A HIGH SCHOOL DIPLOMA, PARTICIPATION IN GRADUATION CEREMONIES,ATHLETIC PARTICIPATION OR SPECIFIC COURSES CANNOT BE

GUARANTEED.

Opportunities may exist to attend a private school while on the exchangeprogram. Additional tuition charges range from $3000 to $6000. Would you

want to be considered for any placements available at a private school?

Yes No Maybe

To get credit for your semester/year abroad, does your home school haveany specific requirements? If yes, please describe:

PARENT/ GUARDIAN INFORMATION

I live with: Father Step-Father Other

Family Name

First Name Age

Occupation

I live with: Mother Step-Mother Other

Family Name

First Name Age

Occupation

AgeFormer

ExchangeStudent?

AtHome?

Which Countryor State?

Which ExchangeProgram?

YearNames Sex

SIBLING INFORMATION


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First Name Middle NameLast Name

Street Address Apartment Number

CityCounty/District

Country

Email Address

Postal Zone

State/Province

IDENTIFICATION NUMBER:________________(For WE Use Only)

First Name

Employer

Country of Birth

Cell Phone

Family/Last Name

Country of Citizenship

Email Address

Business Phone

STUDENT INFORMATION

PARENT and GUARDIAN INFORMATION

3

Telephone Number

City and Country of Birth Country of Citizenship

Country of Legal Residence Passport Number(if presently known)

Country Issuing Passport Expiration Date (mm/dd/yyyy)

Parent/Guardian #1:

First Name

Employer

Country of Birth

Cell Phone

Family/Last Name

Country of Citizenship

Email Address

Business Phone

Parent/Guardian #2:

Parent That Does Not Live With Me:

First NameLast Name

Street Address Apartment Number

CityCounty/District

Country

Email Address

Home Phone

State/Province

Cell Phone

Country of Birth Country of Citizenship

Occupation Employer

Postal Zone

Business Phone

Age


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PERMISSION FOR MEDICAL CARE AND RELEASE

Please fill in the blanks for an emergency contact other than your parents.

Date Signature of Mother/Guardian Signature of Father/Guardian

We, the applicants parents or legal guardians, agree to authorize World Experience or the host family listed below to act for us in anyemergency, accident, or illness during the periods of time our son/daughter is involved in the program.

We authorize World Experience to submit our son/daughter for the required tests if drug/alcohol use or abuse is seriously suspected.

We understand that World Experience, as part of the program fee, will cover participants in homestay programs with accident andmedical insurance. The insurance will cover the usual, customary, and reasonable expenses incurred by a student up to $50,000, asapproved and recommended by a physician and as listed on the schedule of services shown in the Security Passport for WorldExperience Participants designed by AVI International.

In the event our son/daughter has a reoccurrence of any previous illness or anything contracted before leaving home which is notcovered by World Experience insurance, we authorize WE to release our son/daughter to our personal care. We agree not to holdWorld Experience responsible for any expenses incurred by reason of pre-existing illness and agree to pay for an early return home ofour son/daughter if it is deemed necessary after consultation between WE staff members, designated medical authorities andourselves.

We also agree that any expenses incurred for dental work or eyeglasses, unless resulting from an accident while the student is on theprogram, will become our own personal financial responsibility.

X X

HOST FAMILY

EMERGENCY CONTACT

4

Family/LastName of Applicant First Name Middle Name

Street Address

City County/District State/Province

Country Postal Zone Parent Telephone Number

Parent Cell Number Parent Email Address

Parent #1 Family Name/Last Name First Name

Parent #2 Family Name/Last Name First Name

Street Address


Country Postal Zone Telephone Number

Cell Number Email Address

Family/LastName First Name Relationship To You

Street Address


Country Postal Zone Telephone Number

Cell Number Email Address


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EYES

Visual Acuity:Visual Acuity with prescribed glasses:

EARSOtoscopic:

Hearing:

NOSE:

PHARYNX:

NECK

Thyroid:

Glands:

CHEST

Heart:Rate:

Blood Pressure:

Sounds:

Lungs:

ABDOMEN:

EXTREMITIES:

GENITALS:

REFLEXES:

SIGNS OF EMOTIONAL INSTABILITY:


Right Left Type of Test

Right Left

You should not travel before having a dental exam and being sure that all problems are cleared. If you wear braces and will still havethem while overseas, ask your orthodontist to write a letter explaining the corrective system used so that you can give this to an

orthodontist overseas if you need help. The name of the dentist should be printed below and also signed.

ON THE BASIS OF MY EXAMINATION, I HEREBY CERTIFY THAT THE APPLICANT CURRENTLY HAS A HEALTHYDENTAL RECORD AND NO FORESEEABLE DENTAL PROBLEMS.

All spaces should have an entry (such as normal or abnormal). Any abnormalities should be explained seperately. Check that the doctorname and address are printed legibly and that it is signed by the doctor. He/she is responsible for all entries on the Report of Healt

Examination.This includeds sections titled Medical History, Required Immunization Schedule for Schools and Physical Examination.

Please complete all items in ENGLISH.

Name of Dentist (Please Print)

X

Name of Physician (Please Print)

X

Signature of the Dentist

Address:

Address:

City:

City:

State or Country:

State or Country:

Date:

Date:

Telephone:

Telephone:

X

Signature of the Physician

X

II. PHYSICAL EXAMINATION

V. DENTAL EXAMINATION

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On the basis of my examination, I hereby certify that the

applicant is in good health, free from physical or emotionalimpairments, and is able to carry on a full course of study. I

also certify that the information entered in all sections of the

Report of Helath Examination is correct to the best of my

knowledge on the date signed below.

HEIGHT: WEIGHT:

ALLERGIES: Yes No

If yes, please describe the type of allergy and any medications taken:

Does the student take any other medications not already

described? If yes, please identify the medication(s) and the

reason the student is taking them.

Date of last dental exam: Does the student have braces? Yes No

Will the student need orthodontic or other dental care while on the program? Yes No

Please describe:


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Your personal statement should be typed (or written in black ink), single spaced,and composed by you. Please write

this letter using the language of your host country. Discuss the following topics:

1. Describe your family and family relationships. How would your family describe you?2. Describe a school day, vacation day and activities with friends. What activities are important to you?

3. Explain a time in your life when you experienced a challenge. What was the challenge and how did youovercome it?

4. Why do you want to be an exchange student? Why should a host family select you to live with them?5. What are your goals for the future? How will this exchange program help you achieve these goals?

Please use an additional sheet of paper if you need more space.


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LETTER TO HOST FAMILY


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8

LETTER FROM THE NATURAL PARENTS

Your son or daughter is about to spend a year or a semester becoming a member of another family. Please

write a letter introducing your family and your child. This letter should be typed or written in black ink.Please write this letter in English or in the language of the host country. Below are some suggested topics:

1. Describe your family and family relationships.2. Describe your childs friends, interests and activities.

3. Explain the character and level of independence of your child.4. Include any additional comments that would be helpful for World Experience or the host family to know about your

child.

Please use an additional sheet of paper if you need more space.


9/15


Please attach a few photos(or color copies) of yourself, your family and your friends. BE CREATIVE!!! Remember todescribe each photo. Feel free to add additional pages, if needed. These photos will not be returned to you.

PHOTO ALBUM

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PLACEMENT INFORMATION AND PREFERENCES

Religious Affiliation (if any):

How often do you participate in religious services?

Weekly Monthly Holy Days Never

Do you smoke? Yes No Sometimes

Are you a vegetarian? Yes No

Do you have other dietary restrictions or allergies?

Yes No

Please explain:

Can you live with pets?Indoors Outdoors None

Please describe any problems living with pets:

How did you hear about World Experience?

Please answer yes or no to the following questions. Try to be open to all host family possibilities. The more times you say

no, the more difficult it will be to place you.

Can you live with:

A single parent A retired/older couple A younger couple

A baby/toddler A pre-teen A teenager No children

Can you live:

On a farm In a rural area In a small town In a city

In a spotless house In a cluttered house

ABOUT ME

Favorite School Subjects:

Favorite Foods & Restaurants:

What I Like To Cook:

Hobbies:

Favorite Authors/Books:

Favorite Music Styles & Singers:

Favorite Movies/TV Programs/Stars:

Some Of My Favorite People Are:

What Bothers Me:

Profession I May Want To Pursue:

I Would Like To Become Better At:

I Would Like To Learn:

What Like Best About Myself:

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DIRECTIONS:

1. List the information for each grade level in each column (grade level, subjects taken, number of hours per week for each subject, andthe final mark). If you are currently in the 9th or 10th grade, you must still include 3 years of grades. This might include your 7thand/ or 8th grade transcripts.

2. This document needs to be reviewed and signed by a school official/counselor or WE director.

Student Name: This school is in session for weeks per year.

ENGLISH

MATHEMATICS

Arithmetic

Geometry

Algebra

Trigonometry

Other:

SCIENCE

Life Science

Physical Science

Earth Science

Chemistry

Physics

Biology

Other:

SOCIAL SCIENCE

History/Native Country

World History

Government

Comparative Gov.

Geography

Sociology

Other

HEALTH

PHYSICAL EDUCATION

FOREIGN LANGUAGE

MUSIC

ART

OTHER SUBJECTS

MARKHPW= Hours Per Week HPW HPW HPW HPWMARK MARK MARK

Name and Signature of School official or WE Director Date


FOREIGN SCHOOL COURSE RECONSTRUCTION FOR WORLD EXPERIENCE STUDENTS

SUBJECT YEAR GRADE YEAR GRADE YEAR GRADE YEAR GRADE

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We agree to the following terms of participation:

1. Our son/daughter has our permission to take part in a program sponsored by World Experience.

2. World Experience will make every effort to find a suitable family for our son/daughter. However, if a family is not found, we will not hold WorldExperience responsible for any arrangements we have or have not made.

3. We have encouraged our son/daughter to prepare well for the intercultural exchange program because we realize this preparation is invaluabletoward making the whole experience successful.

4. We have read the World Experience Code of Conduct included in this application and we will abide by the rules therein. If our son/daughter breaksa rule found in this document, we understand World Experience has the authority to send our child home early and the fees paid will not be refunded.

5. We understand that our child will be treated like a member of the host family and not as a guest. Therefore, he/she will be expected to respect thehost parents, follow the rules of the host family, and accept normal family responsibilities,

6. We will not visit our child without prior permission from World Experience. We understand that permission might not be given. Unless invited by thehost family in writing, we will not expect to stay with them if we come to visit.

7. We understand our child will NOT be allowed to return home for a visit while on the World Experience program.

8. We will limit our communication to one telephone call per month (or on special occasions) and emails once per week. Infractions of these rules canresult in termination of this contract and the student can be removed from the program.

9. Our child will not take a laptop or cell phone to the host country. We understand these items encourage excessive communication with the homecountry. If the student comes with one of these items, they will be taken away from them and returned at the end of the program.

10. We agree to pay for additional tutoring if the school determines our child has insufficient language ability.

11. We understand that our childs personal drinking and smoking habits will be in accordance with my statement on the application, the laws and rulesof my host country, host community, and host family. If it is illegal to smoke or drink alcohol in the host country, we understand our child will be senthome for smoking or drinking alcohol while on the program.

12. We agree to attend all required orientations that may be scheduled before, during, and after our childs participation in this program. Weunderstand our child will be required to attend orientations during his/her stay in the host country.

13. We agree to supply our son/daughter with the amount required for personal spending money and will pay any personal expenses incurred byhim/her while on the World Experience program. The amount required will vary depending on the location of the placement in the host country.

14. We agree that our child will remain in the host country until the completion of the school term. We will not expect him/her to return at ourconvenience but will respect the schedule of the school that has agreed to educate him/her.

15. We have read and understand the following rules concerning the World Experience refund policy:The registration fee is not refundable.The administration fees are not refunded after the receipt of the application and acceptance of the student.The insurance fee is only refundable prior to placement.The national development and international development fees will be refunded on a pro-rated basis, prior to placement only.No fees will be refunded after a student has been placed in the host country.

16. We GIVE DO NOT GIVE permission for World Experience to use our childs photograph for printed or electronic publicity materials.

17. We GIVE DO NOT GIVE permission for our child to attend optional activities/trips that may be organized by World Experience. Wewill not hold World Experience liable for any damages that may result if my child participates in these activities/trips.

Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American

Arbitration Association under its Commercial Arbitration Rules in the state of California, County of Los Angeles, and the judgment on the award ren-dered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

By signing below we certify that we have read the terms stated above and agree to said terms.

PARTICIPATION AGREEMENT

Student Name:

Student Signature: Date:

Parent/Guardian #1 Signature: Date:

Parent/Guardian #2 Signature: Date:


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has listed you as a personal reference for his/her application to be an exchange student

abroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware ofwhen considering him or her.

has listed you as a personal reference for his/her application to be an exchange studentabroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware of

when considering him or her.

has listed you as a personal reference for his/her application to be an exchange studentabroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware of

when considering him or her.

WORLD EXPERIENCE

2440 S. Hacienda Blvd. Ste. 116Hacienda Heights, CA 91745

WORLD EXPERIENCE

2440 S. Hacienda Blvd. Ste. 116

Hacienda Heights, CA 91745

WORLD EXPERIENCE

2440 S. Hacienda Blvd. Ste. 116

Hacienda Heights, CA 91745

1. In what areas has this student demonstrated above-averagescholastic achievement?

2. In what specific ways has this student shown leadership potential?3. How well does this student relate to peers? To Adults?

1. Describe this students relationships with other members of his/herimmediate family.

2. What personal characteristics does this student have that wouldenable him/her to adjust successfully to living with another familyabroad?

1. Describe the extent of this students involvement in communityactivities.

2. How well does this student relate to peers? To Adults?3. In what specific ways has this student shown leadership potential?

3. Please rate this student on the basis of flexibility, open-mindedness,sense of adventure, sense of humor, friendliness, aggressivenessand active curiosity.

4. How has this student demonstrated maturity, honesty, reliability and/oresponsibility to a degree that would enable him/her to be asuccessful exchange student?

5. Please rate this student on the basis of flexibility, open-mindedness,sense of adventure, sense of humor, friendliness, aggressivenessand active curiosity.

4. Describe this students involvement in extra curricular activities.5. How has this student demonstrated maturity, honesty, reliability

and/or responsibility to a degree that would enable him/her to be asuccessful exchange student?

To the person designated as a SCHOOL REFERENCE:(principal, counselor, or teacher)

To the person designated as a PERSONAL REFERENCE:(a personal acquaintance who knows the applicant well; may not be a relative or an employer)

To the person designated as a COMMUNITY REFERENCE:

(employer, clergyman, neighbor, scout leader, etc.)

PLEASE RETURN THIS WITH YOUR

RECOMMENDATION

CONFIDENTIAL

PLEASE RETURN THIS WITH YOUR

RECOMMENDATION

CONFIDENTIAL

PLEASE RETURN THIS WITH YOURRECOMMENDATION

CONFIDENTIAL

You are required to submit three separate letters of reference foryour application. These must come from three individuals who

are NOT members of your immediate family (household). Theseletters will be held in strictest confidence by WE.

Your SCHOOL REFERENCE should come from a principal,

counselor, or a teacher.

Your PERSONAL REFERENCE should come from a personal

acquaintance who knows you well, but this person may NOT bean employer or relative.

Your COMMUNITY REFERENCE should come from acommunity person who knows you: an employer, clergyman,

neighbor, scout leader or similar individual.

Begin the process of getting your reference letters byobtaining three business sized envelopes. Pre-address and

pre-stamp these for mailing - either to the international office ofWE in Hacienda Heights, California if you are a USA student, or

to the national office of WE in you own country if you are not aresident of the USA.

Note below three coupons, each prepared for a different kind ofrequired reference: School, Personal and Community. On each

of these coupons, in the space provided for the Applicantsname, PRINT your own name. Cut the coupons apart and

attach each to one of the pre-addressed and pre-stamped

envelopes. These envelopes with coupon attached should thenbe hand-delivered to the three individuals who have agreed to

write letter of reference for your application.

PERSONAL REFERENCES

Documents

Student Application 2008