student application checklist - iep brazil · this student application checklist is provided for...
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Student Application Checklist Complete Student Name: _________________________________________________ Family Name First
Passport:
Country of Issue:____________________ Number:______________ Expires:________
This student application checklist is provided for your convenience as verification of completion of all requested information.
• All information must be completed by the appropriate individuals.
• Letters to the Host Family should be typed or printed and discuss the student’s personality, likes, dislikes, family, community and any additional information that will help the Host Family know the student better.
• School transcripts must be translated into the German grade system, with an explanation of the grading system.
• Photos are extremely important.Photographs of a happy, smiling student are often a primary decision factor in the selection of a student by a Host Family. Photos of the student, family, favorite activities, home, etc. should be provided on the photo pages.
• Please complete the pages in German where it is required!
Enclosed:
___________ 1. Student Application
___________ 2. Student Questionnaire
___________ 3. Student’s and Biological Parents’ or Guardians’ Letters to Host Family
___________ 4. Photo Album
___________ 5. Standards of Conduct Agreement
___________ 6. Releases and Authorizations
___________ 7. Medical Information/Immunization History
___________ 8. Academic History for Past Three Years / Letter of Recommendation
___________ 9. German Oral Interview
___________10. Alcohol Authorization Form
Agent Information:
(Please put stamp here)
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Student Application Please fill out this application completely by typing or using black ink. Please attach 4 passport pictures!
Application for: � Academic Year � One Semester @@ � 3 month � 8 weeks Entry Date: � August � January � March
Student Last Name:__________________________FirstName:_____________Middle:________________ Street Address:_________________________________________________________________________ Postal Code:_______________City:______________________State:______________________________ Country:_______________________Telephone:_______________________________________________ Country Code City Code Home Number Birth City:______________________ Birth Country:____________________ Date Birth:_____/_____/_____ Month Day Year Citizenship:___________________ Nationality:__________________ Age:______ Gender:_____F _____M E-mail address:______________________________________ Please check all that apply: I live with: Mother Father @@@@� Mother � Father � Living @@� Living @� Grandmother � Grandfather � Deceased @� Deceased � Other, please explain_________________________ Father’s Last Name:_________________First Name:_________________Occupation:_________________ ______________________________________________________________________________________ Address Postal Code City Country _________________________________________Age:_______ Speaks German: � Yes � No Home Telephone Business Telephone
Mother’s Last Name:_________________First Name:_________________Occupation:________________ ______________________________________________________________________________________ Address Postal Code City Country
_________________________________________ Age:_______ Speaks German: � Yes � No Home Telephone Business Telephone
Please list all other members of your household: Name Age Gender Relationship ______________________________ ____________ ____________ _____________________________ ______________________________ ____________ ____________ _____________________________ ______________________________ ____________ ____________ _____________________________
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YOUR INTERESTS
Please tell us about yourself: What is your religious affiliation? ____________________________________________________________ When do you participate? � Weekly � Monthly � Holidays � Never If your host family’s religion is different than your own, would you be willing to participate? � Yes � No Do you ever smoke? � Yes � No Can you adjust to a home where others smoke? � Yes � No Do you like animals? �Yes � No List any pets you have at home___________________________
________________________________________________________________________________________________
In this section, place an “X” in front of the activities you enjoy. Circle the “X” of the 5 activities you enjoy the
most. SPORTS: ARTS & ENTERTAINMENT: PERSONALITY TRAITS: _____Aerobics _____Attending Sporting Events _____Active _____Open _____American Football _____Dancing-Ballet,Classical _____Adaptable _____Optimistic _____Archery _____Drama-Theater _____Bright _____Organized _____Badminton _____Flower Arrangement _____Calm _____Patient _____Baseball _____Going to the Movies _____Charming _____Polite _____Basketball _____Listening to Popular Music _____Cheerful _____Quiet _____Bicycling _____Listening to Classical Music _____Communicative _____Relaxed _____Camping _____Painting-Drawing _____Considerate _____Reliable _____Field Hockey _____Photography _____Curious _____Realistic _____Fishing _____Playing Indoor Games/Cards _____Emotional _____Reserved _____Golf _____Playing Musical Instruments _____Enthusiastic _____Respectful _____Gymnastics _____Playing Team Sports _____Extroverted _____Responsible _____Hiking/Backpacking _____Playing Individual Sports _____Flexible _____Sense of Humor _____Horseback Riding _____Reading _____Formal _____Sensitive _____Ice Hockey _____Singing _____Friendly _____Serious _____Ice Skating _____Visiting Museums _____Independent _____Shy _____Martial Arts _____Watching Television _____Informal _____Sincere _____Sailing OTHER ACTIVITIES: _____Intellectual _____Smiling
_____Skiing-Snow _____Chess _____Intelligent _____Spontaneous _____Skiing-Water _____Computers _____Intuitive _____Stable _____Snowboarding _____Cooking _____Kind _____Studious _____Soccer _____Debating _____Mature _____Talkative _____Swimming _____Gardening _____Motivated _____Tolerant _____Tennis _____Handicrafts _____Natural _____Traditional _____Track-Running _____Knitting/Sewing _____Neat _____Well-mannered _____Volleyball _____Scouts LIST MUSICAL INSTRUMENTS YOU PLAY:
_____Windsurfing _____Social Dancing ______________________________________ ______________________________________ FOREIGN LANGUAGES YOU SPEAK OR HAVE STUDIED:
Language Years of Study Proficiency German ____________ ____________________________ __________________ ____________ ____________________________ __________________ ____________ ____________________________ What grade in school are you currently attending?_________________Next Year?____________________
Have you or will you have graduated from secondary school when you begin your program ? µ Yes µ No If you choose for your child to attend a private high school which tuition range are you willing to pay per month? � @up to Euro 100 @@@@@� @Euro 200 to 500 @ � @Euro 500 and up
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TO BE COMPLETED IN GERMAN!!! FRAGEBOGEN (Questionnaire) Dieser Fragebogen soll deiner zukünftigen Gastfamilie helfen, dich besser kennenzulernen. Bitte beantworte die folgenden Fragen warheitsgemäß. 1. Der kulturelle Austausch und die Verbesserung deiner Sprachkenntnisse sind zwei Gründe, warum du
diesen Austausch machen möchtest. Nenne bitte zwei weitere Gründe. ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ 2. In einem fremden Land zu leben ist mit Umstellungen und Schwierigkeiten verbunden. Warum glaubst
du, bist du dieser Situation gewachsen? ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ 3. Beschreibe einen Nebenjob oder ein Praktikum, das du bereits absolviert hast. ___________________________________________________________________________________
___________________________________________________________________________________ 4. Welche Zukunftspläne hast du und wie willst du sie erreichen? ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ 5. Beschreibe Tätigkeiten, die du gemeinsam mit deiner Familie unternimmst.
___________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
6. Wie gut kannst du die Gefühle von anderen einschätzen und darauf eingehen? ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________
___________________________________________________________________________________ 7. Hast du bereits in einem anderen Land gelebt? (Wenn ja, wann und wo?) ___________________________________________________________________________________
___________________________________________________________________________________ ___________________________________________________________________________________ 8. Bitte schreibe etwas über deine internationalen Erfahrungen. ___________________________________________________________________________________
___________________________________________________________________________________ 9. Hast du bereits ein Schuljahr im Ausland verbracht? (Wenn ja, wann und wo?) ___________________________________________________________________________________
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TO BE COMPLETED IN GERMAN!!! FRAGEBOGEN (Questionnaire) 9. Was erwartest du von deiner zukünftigen Gastfamilie? Was kannst du in das Familienleben einbringen? ___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
10. Schildere ein Beispiel für deine Offenheit gegenüber anderen Menschen und neuen Ideen. ___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
11. Während deines Austausches musst du dich auf viele neue Gegebenheiten einstellen wie z.B. das
Essen, die Schule, Familienregeln, Gesetze u.s.w. Beschreibe, wie du vor hast, dich auf diese Veränderungen einzustellen.
___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
12. Mit welchen drei Probleme glaubst du konfrontiert zu werden und wie wirst du mit ihnen umgehen? ___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
13. Was glaubst du, ist besonders an dir? ___________________________________________________________________________________
___________________________________________________________________________________ 14. Viele Schüler haben Träume und Wünsche. Welche sind deine? ___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________ 15. Wenn du etwas auf der Welt verändern könntest, was wäre das?
___________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________ 16. Gibt es noch etwas, was du deiner Familie mitteilen möchtest? ___________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________
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TO BE COMPLETED IN GERMAN!!! EIN BRIEF VON DIR (A letter from you)
Dieser Brief ist der wichtigste Teil deiner Bewerbung. Dein Brief wird der Gastfamilie helfen deine wahre Persönlichkeit kennen zu lernen. Der Brief soll so nett und offen wie möglich geschrieben werden. Versuche möglichst nichts zu wiederholen, was du bereits in den anderen Unterlagen erzählt hast. Vergiss nicht den Brief zu Unterschreiben.
------------------------------------------------------------------------------------------------------------------------ Dieser Brief sollte auf deutsch sein. Du kannst ihn gerne am Computer schreiben.
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TO BE COMPLETED IN GERMAN!!! FOTOALBUM Bitte klebe hier einige Fotos von dir, deiner Familie, Freunden Haustieren und allem was dir in deinem Leben wichtig ist auf. Du musst dich nicht an die Vorlage halten und kannst die Fotos auch auf einem extra Blatt zusammenstellen. Wichtig ist, dass du jedes Foto sorgfältig beschriftest, damit deine Gastfamilie auch weiß, was sie auf dem Foto sieht.
Beschreibung: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________
Beschreibung: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________
Foto 1
Foto 2
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Beschreibung: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________
Beschreibung: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________
Foto 3
Foto 4
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A LETTER FROM YOUR PARENTS
This letter, along with your child’s, will normally have the most influence on prospective families. To help the Host Family understand your child’s personality, background, life-style and habits, you should provide detailed and personal data. Information that has been provided in other sections of this application should not be repeated. Please sign your complete name to the letter. ______________________________________________________________________________________ This letter can be in English and typed. Please write your letter within the space provided.
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YOUR ACADEMIC HISTORY Student Name:__________________________________________________________________________
Grading Scale Foreign
Germany Grading Scale Comments ___ Excellent 1 A+/A ______________________________________________ Above Average 2 A-/B+ ______________________________________________ Average 3 B ______________________________________________ Poor 4 C/D ______________________________________________ Fail 5 F ______________________________________________ In the boxes below, please list the courses taken and the grades received from the 8th level to the present using the grading system as listed above. IMPORTANT: PLEASE ATTACH A COPY OF EACH SCHOOL REPORT MENTIONED BELOW.
Calendar Year: 200___ School Grade: ______ Calendar Year: 200___ School Grade: ______
Courses Hours per 1/2 Year Final Courses Hours per 1/2 Year Final Week Grade Grade Week Grade Grade _____________________________________________________ _____________________________________________________
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Calendar Year: 200___ School Grade: ______ Calendar Year: 200___ School Grade: ______
Courses Hours per 1/2 Year Final Courses Hours per 1/2 Year Final Week Grade Grade Week Grade Grade _____________________________________________________ _____________________________________________________
_____________________________________________________ _____________________________________________________
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This course translation was prepared by:
Signature:__________________________________________________________Date:________________________________
Official Title:________________________________________________________School Stamp:___________________
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GERMAN KNOWLEDGE To the German teacher Please circle the scale (1 to 10) which best describes this student’s ability to understand and speak German. Use the guidelines next to each number for your evaluation.
10 Absolute proficiency in German. Student is able to both understand and converse, dealing
with abstract terms. Thinks in German. 9 Student possesses near fluency. Sentence structures are near perfect. Can understand and
respond to difficult questions. German knowledge includes abstract terms. Will have no problem at all in communication when he/she arrives in Gemany.
8 German responses, although not perfect, come naturally. In other words, student responds
clearly in German. Has good vocabulary and understands almost everything. Can respond intelligently, but needs practice.
7 Student can understand a lot. Speaking ability is good, but needs practice. Student can go
beyond basic responses. Knows many words, but needs to think before responding. 6 Student understands basic German. Vocabulary deals with everyday common terms. Thinks
quickly, but it is evident that he/she is translating. Gets lost when conversation departs from basics. Makes mistakes, but is understandable. Can carry on a conversation.
5 Student can understand much more than he/she can communicate, however makes an effort. Can respond in some sentence forms even if grammar and structure are not perfect.
4 Student evidently understands basic German sentences and is able to respond even if only in words. Grammar and sentence structure are poor, but understandable. A few weeks of
total immersion in German will improve his/her ability. 3 Student understands words, but not sentences. Speaking ability is limited to a few words.
2 Student understands a few words, but has little or no ability to communicate.
1 Student cannot understand and knows little or no German.
Please give your reasons for this score and any suggestions you may have for this student.
______________________________________________________________________________________
Briefly describe your relationship with this student.
________________________________________________________________________
Name of German teacher:____________________________________Date:___________________
Position:_________________________________________________________________________
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LETTER OF RECOMMENDATION This section is to be filled out by a Teacher or Counselor. Thank you for completing this form (in English) for the below-named student, who wishes to spend a semester or year, living with a family abroad and attending high school. Your evaluation will be held in strict confidence. Please return it to the Exchange Representative in your country, not to the applicant.
Student Name:__________________________________________________________________________________ Name of Teacher or School Counselor:______________________________________________________________ Name and Address of School:______________________________________________________________________
________________________________________________________________________________________________
Please rank the student in comparison with his/her classmates by making an “X” in the appropriate box. Category Top 10% Top 25% Top 50% Bottom 50%
Academic Ability
Academic Performance
Positive Attitude toward School
Neatness
Stability
Maturity
Adaptability
Leadership Capabilities
Cooperativeness
Friendliness
Potential as Exchange Student
How long and in what capacity have you known this student?______________
Does this student have a history of continuous absence from school? O Yes O No
What is the student’s attitude toward school and school work? O Good O Average O Poor
What is this student’s relationship with his/her fellow classmates?
O Leader O Cooperative O Uncooperative
Based on your knowledge of this student, how would you evaluate his/her potential success as an exchange student?
O Very Good O Good O Average @O Poor
Please add any other information you think is appropriate:________________________________________
Signature:_____________________ Date:_________________________
Title:_________________________
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MEDICAL INFORMATION
Student Name:__________________________________________________________________________ Date of Birth:_____/_____/_____ City and Country of Birth:__________________________________
PHYSICAL EXAMINATION OF STUDENT
(This examination is to be done by a Medical Doctor)
Height_______________Weight_______________Blood Pressure________________Pulse_____________ Visual Acuity Hearing (Without Correction) R______/_______ L______/______ R______/_______L______/______ (With Correction) R______/_______ L______/______ R______/_______L______/______ Respiratory System______________________________________________________________________ Cardiovascular System____________________________________________________________________ Neurological System______________________________________________________________________ Musculoskeletal System___________________________________________________________________ Urinalysis S.B.________________Alb_________________Sugar_______________Micro_______________ E.N.T.________________________Liver__________________________Spleen______________________ Abdomen_____________________Skin__________________________Genitals_____________________ Comment regarding abnormalities___________________________________________________________ Significant past illness or injury______________________________________________________________ Please specify any allergies________________________________________________________________ Medication currently being taken____________________________________________________________
STUDENT’S MEDICAL HISTORY Please mark answer yes or no
If you answered “yes”, please explain on a separate sheet. Yes No Yes No
Measles ______ ______ Chicken Pox ______ ______ Rubella ______ ______ Kidney disease ______ ______ Mumps ______ ______ Congenital anomalies ______ ______
Allergies ______ ______ Menstrual disorder ______ ______ Eye problems ______ ______ Orthopedic problems ______ ______ Hospitalization ______ ______ Convulsions ______ ______
Pulmonary disease ______ ______ Neurological disorders ______ ______ Cardiac disease ______ ______ Accidents ______ ______
Endocrine disorder ______ ______ Operations ______ ______ Eating Disorder ______ ______ Emotional or mental disorders ______ ______
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IMMUNIZATION RECORD
This information is for our records - the immunizations are NOT compulsory Student Name:_________________________________________________________________________ Date of Birth:_____/_____/_____
Vaccine Give date each dose was given. 1st 2nd 3rd 4th 5th Polio (TOPV) _____/_____/____ _____/_____/_____ _____/_____/____ _____/_____/____ _____/_____/_____ DPT and/or DT (Diptheria,Tetanus & Pertussis or Whooping _____/_____/____ _____/_____/_____ _____/_____/_____ _____/_____/____ ____/_____/_____ Cough) OR (Tetanus and Diptheria)
Measles (Rubeola - 10 day,
red measles) _____/_____/_____ If no immunization, give date student had measles _____/_____/_____
Rubella (German measles,
3 day measles) _____/_____/_____ If no immunization, give date student had rubella _____/_____/_____
Mumps _____/_____/_____ If no immunization, give date student had mumps _____/_____/_____ Hepatitis B _____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____ _____/_____/_____
I, the undersigned, have given a thorough physical examination and reviewed the medical history of this student. I certify that all important medical information has been included, and that the above information is complete and accurate.
Physician’s Signature:____________________________________________Date:____________________ Physician’s Name:_______________________________________________________________________ Physician’s Address:______________________________________________________________________
Please affix seal, stamp or provide medical license number for verification purposes.
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STANDARDS OF CONDUCT I. DANGEROUS ACTIVITIES
Skydiving, hang gliding, glider riding, parachute jumping, parasailing, jet skiing, bungee jumping and riding in hot air balloons are prohibited.
II. DRINKING
Consuming alcoholic beverages is not allowed while on the exchange program. However, the legal drinking age in Germany is sixteen. Natural parents and partner agency must sign whether they allow the exchange student to drink alcohol in the physical presence of the hostfamily or if they don´t allow it at all. Please see “Alcohol Authorization Form”.
III. DRUGS
The student is required to refrain from using drugs of any kind (other than prescribed drugs for health purposes). Further, no association is to be maintained with anyone involved with drugs or drug use in any way.
IV. FINAL AUTHORITY
A. Students must respect all decisions made by DFSR and its coordinators or staff. B. DFSR reserves the right to dismiss a student from the program, if there should arise, in the judgment of DFSR officials, a
condition likely to bedetrimental to the health of the student. C. DFSR reserves the right to dismiss a student from the program should the student violate the Standards of Conduct or for
other disciplinary problems.
V. HITCHHIKING Hitchhiking is extremely dangerous. Students are not permitted to hitchhike, either alone or with friends. VI. HOST FAMILY REGULATIONS
Each family has rules and regulations which help it function effectively. It is imperative that each student makes every effort possible to understand what his/her family expects. Each student must be respectful of his/her Host Family and the rules that govern the household. Activities must be approved by the Host Family. At all times, the student’s Host Family must know where the student is, with whom and when the student will return.
VII. LAW VIOLATIONS
If a student admits to a criminal law violation, or is arrested and charged, or if reliable information is received that the student will be arrested and charged, the student will be returned to his/her home country as soon as legally possible. Students are expected to obey all laws of the host country, state, city and community.
VIII. LEAVING THE PROGRAM A student may not leave the program at any time without the express written consent of DFSR. Students are not permitted to return
home during the program. Doing so will be considered leaving the program. When a student leaves the program, except for emergencies, he/she may not return to the program. The student may leave the program due to death or serious illness in the immediate family or for other bona fide emergency situations as determined by DFSR.
IX. MONEY Because each student is responsible to purchase his/her personal items, clothing, entertainment, etc. each student is required to
have at his/her disposal, a minimum of € 150 each month. It is strongly recommended for each student to open up a bank account in Germany. Each student is responsible for his/her own spending money. DFSR is not responsible for any lost or stolen money. It is against DFSR regulations for a student to place his/her money in the Host Family’s bank account. Further, no student shall lend money to, or borrow money from, any member of his/her Host Family.
X LANGUAGE TUITION
Advanced knowledge of German is required for high school entry. If the student does not possess the required level of German knowledge, a minimum number of language lessons will be determined by DFSR on receipt of the German assessment and prior to arrival. Completion of the agreed language course is compulsory for high school entry.
XI. SCHOOL A. The student is on an Exchange-Visitor or Student Visa and must attend school regularly and obey all school rules. B. The student is expected to show an interest in his/her school work and make and effort to do his/her best.
C. If, in the school’s or DFSR’s opinion, the student needs a language tutor to succeed in class(es), DFSR will help to arrange for such a tutor. The cost for tutoring will be the sole responsibility of the student’s natural parents.
D. If the student is given a failing mark in attitude as an official complaint from the school, he/she will be returned to his/her home country.
E. Dismissal from school will result in dismissal from the program.
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STANDARDS OF CONDUCT, Continued XII. SEX
The exchange experience is not intended to be a time in which romantic attachments are formed. The exchange student is an ambassador of his/her country. Therefore, it is extremely important that the student’s moral behavior be beyond reproach at all times. If it is found that a student is involved in a sexual relationship while sponsored through the DFSR program, that student may be returned to his/her own country immediately. If it is found that a student is pregnant while sponsored through the DFSR program, that student will be dismissed from the program.
XIII. SMOKING The student must follow the rules of his host family and refrain from smoking in the home if required. XIV. PORNOGRAPHY Purchase, possession and/or downloading of pornography is not permitted. XV. INTERNET AND E-MAIL While use of the Internet and e-mail is generally deemed acceptable, it may also be detrimental to a student’s program. Students
must respect and abide by host family and school rules in relationshilp to use of computer, Internet and e-mail. XVI. TRAVEL Students will be permitted to travel while in the host country only according to the following conditions:
A. If with the Host Family and if longer than overnight, the DFSR Coordinator must be informed of dates and a phone contact where the student can be reached in case of emergency.
B. If with another family, the Host Family must approve and the same regulations as “A” above. C. School and group-sponsored trips are permitted. Again, Host Family must approve and DFSR Coordinator must be notified. D. If independently to visit another family, the inviting family must confirm the invitation with the Host Family and DFSR
Coordinator. E. Travel by air, bus or train in Germany or Europe is permitted only under the following conditions: 1. Chaperoned group trips. 2. Direct trips from departure point directly to destination, to be met by family visited. Note: Unauthorized travel may be cause for dismissal from the program.
XVII. WORK AND JOBS
Students sponsored by DFSR are in the host country on an Exchange-Visitor Visa. It is against the law for an exchange student to hold a job or seek employment. Exceptions to this may be occasional baby-sitting, lawn mowing or other odd jobs which might be offered to the student by his/her Host Family or the Host Family acquaintances.
XVIII. VISITS FROM RELATIVES AND FRIENDS
Visits from relatives and friends should be restricted to the end of the student’s program. Earlier visits may result in disruption of student/host family adaptation process. Approval of host family must be obtained prior to the visit. Guests may not expect that host families will be able to accommodate them in the host home.
AGREEMENT We, the student and parent(s)or legal guardian, have read and understand all of the above. We agree to obey these rules and understand that disobeying them will result in the student’s dismissal from the program and being returned to his/her home country. _______________________________________________________________ _____________________ Signature of Student Date _______________________________________________________________ _____________________ Signature of Father or Legal Guardian Date _______________________________________________________________ ______________________ Signature of Mother or Legal Guardian Date
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LIABILITY RELEASE We, the undersigned, as the participant, and the parent(s) or legal guardian(s) of a participant in a program organized and directed by DFSR Management, hereby release DFSR, its Officers, Board of Directors, Agents, Coordinators and Schools where the participant may be assigned, from any and all current and future claims, charges, costs and/or causes of action for loss of property, personal injury, illness, accident or death sustained by the participant for the duration of the DFSR program, whether covered by insurance or not. We further understand and agree we are responsible for any loss, damage or injury caused by the participant in the DFSR exchange program. We understand and agree that the participant will be subject to authorities and teachers of the school where he/she may be assigned and that he/she must follow the rules set forth by the Host Family with whom he/she may live. We have read and understand the Standards of Conduct and agree that the participant must follow and abide by these rules and regulations as outlined. As the parent(s) or legal guardian(s) of the participant we agree to supply our child with a minimum € 200,00 per month in spending money to cover his/her needs and expenses for the duration of his/her exchange program and return home. We understand and agree that DFSR is not responsible for my/our child’s money or personal property, whether lost or stolen, while he/she is participating in the DFSR Exchange program. Further, we understand and agree that should there be a geographical move of my/our child, for any reason whatsoever, the cost of transportation shall be borne by the participant. We grant DFSR permission to use photographs, or any other materials in which the participant may appear, for promotion or publicity of the organization’s programs. If we have personally misrepresented, or have knowledge of misrepresentation of any portion of this application, we understand that DFSR has the option of immediately dismissing the participant from the DFSR program and repatriating the participant. In the event of repatriation, we shall bear all costs incurred and understand that any and all program fees are nonrefundable.
_________________________________________________________ _________________________ Signature of Student Date _________________________________________________________ _________________________ Signature of Father or Legal Guardian Date _________________________________________________________ _________________________ Signature of Mother or Legal Guardian Date
TERMINATION OF PROGRAM I/We understand that my/our child’s DFSR Management program terminates one week following the closure of school or at the time of his/her group departure and return to home country, whichever is earlier. DFSR does not accept any responsibility for students who remain within the country as tourists for longer than the stipulated time period. ________________________________________________________ __________________________ Signature of Student Date ________________________________________________________ __________________________ Signature of Father or Legal Guardian Date ________________________________________________________ __________________________ Signature of Mother or Legal Guardian Date
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AUTHORIZATIONS
MEDICAL RELEASE In case of illness, accident or injury, I/we grant permission to DFSR Management , its representatives, the high school where my/our child is enrolled, and/or my/our child’s Host Family to authorize examination and treatment for my/our child, by qualified medical personnel. I/we also grant DFSR, the high school where my/our child is enrolled, and his/her Host Family, all necessary permissions to act as legal guardians, especially in emergencies, whether medical or other, including surgical operations or any other treatment. This authorization also grants permissions to release information regarding my/our child in order to receive any and all inoculations or immunizations required by federal, state and/or school authorities for participation in the DFSR program. This Medical Release Authorization shall be valid for the entire duration of the DFSR program in which my/our child is participating. Signature of Father or Legal Guardian:__________________________________Date:_________________ Signature of Mother or Legal Guardian:__________________________________Date:_________________
TRAVEL AUTHORIZATION I/We authorize DFSR Management, its representatives, and my/our child’s Host Family to allow my/our child to travel, within the guidelines as established in the DFSR Standards of Conduct. It is understood that this authorization is signed in advance and eliminates the necessity of obtaining our signature(s) at the time of any DFSR approved travel for the duration of my/our child’s participation in this program. Signature of Father or Legal Guardian:___________________________________Date:________________
Signature of Mother or Legal Guardian:___________________________________Date:________________
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ALCOHOL AUTHORIZATION We would like to point out that it is forbidden by DFSR and our partner agency _____________________(name of agency) abroad to consume alcoholic beverages while the student is on the exchange program. However, the legal drinking age by law in Germany is 16 years and it is common for young people to drink at family parties for example. Exchange students also often ask their host families if exceptions can be made to the non-alcohol rule. We do not wish our host families to be forced to make the decision to allow or forbid this. Therefore, we ask the natural parents and our partner agency to sign a written agreement with their approval or disapproval of drinking alcoholic beverages. Student Name (Please print name):_______________________________
If this agreement is broken the student can be sent home. Natural parents please confirm: O I/We forbid my/our child to drink alcoholic beverages at all while on the German
exchange program: O I/We do allow my/our child to drink alcoholic beverages only in the physical
presence of the hostfamily. Signature of Father or Legal Guardian:______________________Date:_______________ Signature of Mother or Legal Guardian:______________________Date:_______________ Partner agency please confirm: O ____________________(Name of partner agency) forbids the exchange student to drink alcoholic beverages at all while on the German exchange program. O _____________________(Name of partner agency) allows the exchange student to drink alcoholic beverages only in the physical presence of the hostfamily. Signature of partner agency:________________________________Date:____________
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DFSR INTERVIEW FOR STUDENTS A stay of 2, 3, 5 or 10 months in Germany calls for, as you probably already know, a certain degree of maturity, openness and flexibility. Before you start filling out the application form, we ask you to answer the questions below totally honestly. 1. Can I live without my family, my friends and �yes �no
my accustomed environment for 3, 5 or 10 months? 2. Can I live with and accept a family of a different religion, �yes �no a different race, different skin color and different attitude to life? 3. Would I feel comfortable living with a family of a different social �yes �no level or financial position? 4. Am I willing to tolerate and accept attitudes, moral concepts, �yes �no ways of life, that are contrary to my usual way of living / habits? 5. Am I able to share a room for a few months with my host brother �yes �no or host sister, even though I am used to having my own room?
6. Can I cope with challenges and problems, do I know how to deal �yes �no with possible disappointments?
7. Am I going abroad to learn about the culture, the peculiarities, �yes �no the advantages and problems of this country without constantly comparing the negative sides of this country to my home country?
8. Do I really want to become a family member without expecting to �yes �no be treated like a guest, who will only be shown the best things and cooked the best food?
9. Am I aware that this program is also an academic program, that �yes �no demands good grades from me in school in a school system that is very different from the one in my country with high demands?
10. Am I aware that not only I but also my host family is supposed to �yes �no benefit from this program? If you have been able to answer all questions with „YES“, you have fulfilled the most important prerequisites for successful program participation. Date: Signature: Foreign Agent: