€01€student information 1 · list foreign languages you speak or have studied ... please let us...

STUDENT'S FULL NAME - -

FIRST MIDDLE LAST

NICKNAME/AMERICAN NAME HEIGHT WEIGHT

PROGRAM START DATE August - 2018

HOME ADDRESS (STREET)

POSTAL ZONE

CITY

COUNTRY Thailand

HOME TELEPHONE

EMAIL

DATE OF BIRTH - - AGE SEX FEMALE MALE

CITY OF BIRTH COUNTRY OF BIRTH Thailand

HOLDS US PASSPORT?

PASSPORT NO. EXPIRATION DATE - -

COUNTRY ISSUING PASSPORT Thailand

US PHONE NUMBER? US EMAIL ADDRESS?

ACADEMIC EXCHANGE SELECT SHORT TERM

TRIMESTER 1 SEMESTER 1 SCHOOL YEAR STUDENT 2 YEARS OR MORE

PUBLIC HIGH SCHOOL PRIVATE DAY SCHOOL

CURRENT YEAR OF STUDY IN HOME COUNTRY GRADE ENTERING IN THE US?

PREFERENCE LIST

RELIGIOUS PREFERENCE

INTEREST AND INVOLVEMENT ACTIVE LITTLE NONE

WHO DO YOU LIVE WITH MOTHER AND FATHER MOTHER FATHER OTHER (WHO)

01 STUDENT INFORMATION 1

FATHER OR LEGAL GUARDIAN

NAME FIRST MIDDLE LAST

STREET POSTAL ZONE

CITY

HOME TELEPHONE

OCCUPATION

DATE OF BIRTH - -

COUNTRY Thailand

EMAIL

WORK TELEPHONE

CELL TELEPHONE

MOTHER OR LEGAL GUARDIAN

NAME FIRST MIDDLE LAST

STREET POSTAL ZONE

CITY

HOME TELEPHONE

OCCUPATION

DATE OF BIRTH - -

COUNTRY Thailand

EMAIL

WORK TELEPHONE

CELL TELEPHONE

BROTHERS AND SISTERS

NAME AGE

SEX FEMALE MALE LIVE AT HOME YES NO

NAME AGE


NAME AGE


CURRENT SCHOOL INFORMATION

CURRENT SCHOOL PUBLIC PAROCHIAL PR IVATE

DATES ATTENDED

FROM - - TO - - PRESENT GRADE

ADDRESS (STREET) POSTAL CODE

CITY COUNTRY

PRINCIPAL/COUNSELOR E-MAIL

PHONE FAX

POSITION OF STUDENT IN CLASS

NUMBER OF STUDENTS IN CLASS

FAVORITE SUBJECTS

LEAST FAVORITE SUBJECTS

SUBJECT WHICH ACHIEVES BEST GRADES

SUBJECT WHICH ACHIEVES WORST GRADES

WHAT ARE STUDENT'S ASPIRATIONS?

SLEP TOEFL IELTS SSAT OTHER

CURRENT GRADE POINT AVERAGE

IF THE STUDENT WAS IN US, WHAT VISA WAS HE/SHE ON? (J-1, F-1, B-1...)

FOREIGN COUNTRY STUDIED IN BEFORE YEAR

HOW LONG WAS THE PROGRAM?

STUDENT'S INTERESTS

DOES THE STUDENT HAVE ANY SPECIFIC MEDICAL PROBLEMS/REQUIREMENTS?

02 STUDENT INFORMATION 2

LIST FOREIGN LANGUAGES YOU SPEAK OR HAVE STUDIED

LANGUAGE YEARS OF STUDY PROFICIENCY

English AVERAGE GOOD EXCELLENT

AVERAGE GOOD EXCELLENT



AGENT INFORMATION

AGENCY NAME COUNTRY

CONTACT NAME E-MAIL

MAILING ADDRESS

TELEPHONE NUMBER FAX NUMBER

Please let us know about any allergies or other medical conditions that you may have. This information is necessary for us to be able to handle your application appropriately. Make sure that the information that you enter here is consistent with what your doctor enters in the Student Health Review. If the information entered here is not accurate and complete, we may not be able to accept you on our program.

Does the student have any allergies? Yes No

Does the student have any medical problems? Yes No

Does the student have any specific health-related requirements? Yes No

03 ALLERGIES AND OTHER MEDICAL INFORMAT…

04 PERSONAL STATEMENT

05

PLEASE INCLUDE SEVERAL PHOTOS OF YOU AND YOUR FAMILY . YOU CAN ALSO INCLUDE PHOTOS THAT SHOW US SOMETHING ABOUT YOUR PERSONALITY AND INTERESTS.

PHOTO ALBUM

06 COPY OF PASSPORT

07 TRANSCRIPTS & ENGLISH TEST

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09 - STUDENT'S QUESTIONNAIRE ABOUT YOU WHAT QUALITY DO YOU VALUE MOST IN YOURSELF?

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............................................................................................................................................................................................ WHAT QUALITY DO YOU VALUE MOST IN OTHERS?

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............................................................................................................................................................................................ WHAT DOES YOUR FAMILY ENJOY DOING TOGETHER?

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............................................................................................................................................................................................ WHAT ARE THE RULES YOU MUST RESPECT IN YOUR FAMILY?

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............................................................................................................................................................................................ WHAT DUTIES DO YOU PERFORM AT HOME?

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............................................................................................................................................................................................ WHAT TIME DO YOU USUALLY GO TO BED?

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YOU IN YOUR HOST COUNTRY WHY DO YOU WANT TO LIVE WITH A HOST FAMILY ABROAD?

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............................................................................................................................................................................................ DO YOU HAVE A SPECIFIC REQUEST REGARDING THE HOST FAMILY ARRANGEMENTS? PLEASE REMEMBER THAT WE WILL TAKE ALL REQUESTS INTO CONSIDERATION, BUT WE WILL NOT GUARANTEE THIS REQUEST WILL BE MET.

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............................................................................................................................................................................................ HOW DO YOU PLAN TO MAKE FRIENDS IN YOUR NEW ENVIRONMENT?

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............................................................................................................................................................................................ DO YOU HAVE REQUIREMENTS FOR SPORTS WHILE IN THE US? IF SO, ARE YOU WILLING TO PAY ANY ADDITIONAL FEES IF THIS SPORT IS NOT AVAILABLE IN THE SCHOOL?

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............................................................................................................................................................................................ DO YOU HAVE REQUIREMENTS FOR SPECIFIC CLASSES WHILE IN THE US?

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IS THE LOCATION OF THE SCHOOL, OR THE TYPE OF THE PROGRAM (PUBLIC OR PRIVATE DAY SCHOOL) MORE IMPORTANT? WHY?

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............................................................................................................................................................................................ DO YOU HAVE ANY DIETARY RESTRICTIONS? (VEGETARIAN, RELIGIOUS, ETC.) PLEASE DESCRIBE IN DETAIL.

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............................................................................................................................................................................................ CAN YOU LIVE IN A HOUSEHOLD WITH PETS? IF NOT, PLEASE SPECIFY WHICH PETS YOU CANNOT LIVE WITH AND THE REASON WHY NOT.

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09 - STUDENT'S QUESTIONNAIRE

INTERESTS,

CHECK ACTIVE INTERESTS WITH 1. IF YOU LIKE

BUT DO NOT PARTICIPATE CURRENTLY IN SOMETHING MARK WITH A 2.

NOT INTERESTED = LEAVE BLANK

AEROBIC EXERCISING FISHING SAILING

AMERICAN FOOTBALL GOING TO MOVIES SEWING

ATTENDING THEATER HIKING/BACKPACKING SOAP OPERAS

BALLET DANCING HORSEBACK RIDING SOCCER

BASEBALL ICE SKATING SOCIAL CLUBS

BASKETBALL INDIVIDUAL SPORTS SOCIAL DANCING

CAMPING INDOOR GAMES SKIING

CHESS/BACKGAMMON JOGGING SWIMMING

CLASSICAL MUSIC MARTIAL ARTS SYMPHONY

COLLECTING STAMPS MOTOR VEHICLES TENNIS

COMPUTERS PAINTING/DRAWING VISITING MUSEUMS

COOKING PHOTOGRAPHY VOLLEYBALL

CURRENT EVENTS PLAY AN INSTRUMENT WATCHING SPORTS

CYCLING PLAYING CARDS WATCHING TV

DANCING POLITICAL GROUPS WINDSURFING

DEBATING POPULAR MUSIC WRITING

DRAMA READING OTHER

FASHION RELIGIOUS ACTIVITIES

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STUDENT ENROLLMENT AGREEMENT Educatius International Inc., its agents, principals, sponsors, affiliates, directors, officers, employees and attorneys (collectively “Educatius”), the undersigned parent(s) or legal Guardian(s) (collectively referred to as “Guardian”) and Student (“Student”), understand and agree to the terms and conditions stated in this Agreement (“Agreement”) relating to the Student’s participation in Educatius’ Private Day High School Programs, Public High School Programs, and Boarding School Programs (collectively referred to as “Program”). Guardian and Student are referred to collectively as the Participants (“Participants”). Adult(s) and their resident children who agree to host a Student for the Program term are referred to as the Host Family (“Host Family”). The terms “host country” and “USA” refer to the United States of America. A. Admission and Placement: Educatius considers criteria such as: the Student's application packet materials, academic background, high school transcripts, age, education level, physical and mental health, references, personal letter, English-language test score(s), and personal interviews in determining whether to admit the Student into the Program. Educatius has the sole discretion to determine whether the Student will be admitted into the Program and such determination is final. If the information provided to Educatius for admission into the Program is later discovered to be inaccurate, Educatius retains the right to revoke the admission to the Program and repatriate the Student at the expense of the Guardian. Any costs, expenses, or damages incurred by Educatius because of misrepresentations or inaccuracies made by Participants will be recoverable by Educatius from Participants. B. Host Family Placement: Educatius host families go through a thorough selection process. Educatius requires that a host family is willing to provide a good and stable environment for the Student. Educatius further requires that the home offers enough space for the Student, that the home meets reasonable standards regarding comfort and cleanliness and that the home is no longer than a 45 minute one-way commute from the school. If Educatius finds that a host family no longer meets these requirements, a new host family will be offered to the Student. Any host family placement will have gone through Educatius’ internal quality control process and be approved before being offered to the Participants. The average makeup of a host family may vary. All preferences and characteristics of the Student may not be accommodated in the placement process. In some cases, Student may be placed with a single-parent host family with no other minor children in the home and/or in a home with one additional exchange student. Other factors such as host family ethnicity, national origin, race, extended family structure, age, and religion may also vary. The types of housing may differ depending on the location the Student chooses to attend school as well as other factors. The Student may be placed in an apartment building in the city, or a large home in a suburb. Educatius will take specific requests into consideration but will not guarantee to meet any such requests. By signing below, the Student and the Guardian hereby agree to such placement. C. Host Family Change: Any host family change initiated by the Participants will be subject to a host family change fee of $500 payable by Participants. D. Air Travel: Guardian agrees to purchase a round-trip ticket for the Student’s travel between home and host countries. Educatius has the right to seek reimbursement for any and all costs associated with air travel for the Student in the event an airline ticket is not provided by the Guardian. If the Student is dismissed from the Program, leaves the Program early for any other reason, or returns to Student's home country, or any other country, for any reason, any transportation expenses will be paid for in full by the Guardian. By signing below, the Guardian guarantees that the return travel will be booked within the time frame given by Educatius. If Educatius is required to arrange the Student's travel, the Guardian agrees that Educatius has no duty or obligation to consider travel cost or Participants' convenience when making travel arrangements. Should legal proceedings become necessary with regard to recovery of air travel costs, the prevailing party shall be entitled to recovery of any and all legal fees and costs.

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Students are permitted to arrive up to seven days before the school start date. Arrival earlier than 7 days before the school start date is not allowed without prior approval in writing from Educatius and will incur additional costs payable by Participants. Students are permitted to depart up to ten days after the school end date. Departure later than 10 days after the school end date is not allowed without prior approval in writing from Educatius and will incur additional costs payable by the Participants. If Student arrives at any other airport than what is suggested by Educatius, a pick up fee of $250 will be charged, payable by the Participants. Additionally, for insurance purposes as well as arrangements for airport pick up, Educatius must be notified prior to the departure of the Student from Student's home country to the host country. Guardian will be responsible for any and all medical, accident, and/or liability costs incurred due to failure to inform Educatius of flight arrival information resulting in lack of proper insurance coverage. E. Guardian Accompanying Student: While it is understandable that Guardian, family members, or other acquaintances may wish to travel with the Student to the host country, this often severely disrupts the Student’s acclimatization and is therefore strongly discouraged by Educatius. If Guardian, family members, or acquaintances nevertheless chose to travel with or visit the Student during the Student’s time in the Program, Educatius retains the right to advise the Guardian, family members, or acquaintances to leave the area where the Student is staying if it is deemed by Educatius that those staying is disruptive to the Student. If this advice is not adhered to, Educatius may, at its sole and absolute discretion, terminate the Student’s participation in the Program and immediately repatriate the Student to Student's home country at the expense of the Guardian. F. Internet Use: The Student is expected to abide by school and Host Family rules with regard to use of the internet and electronic mail. The Student is not permitted to visit, view or download any pornographic sites/material or other age-restricted sites, nor will the Student be permitted to download materials including but not limited to music, movies, games, applications, photos or the like. Should the Student download such materials, any and all costs associated with such internet use and/or downloads will be the responsibility of the Student and Guardian. Failing to comply with said rules for internet and electronic mail use may be cause for Program termination and immediate repatriation at the expense of the Guardian. G. Dissimilarities or Differences Abroad: In addition to learning the host country’s language, the Student is expected to adapt to the culture and lifestyle of the Host Family and host country. There may be significant cultural, economic and lifestyle differences between the Student’s home country and host country. The host country may have different health care services, living conditions, road and transportation systems, educational approaches and systems, criminal justice systems, civil liberty laws, customs and values. The Program offers numerous opportunities for the Student; however, Participants must be aware and accept these differences and the uncertainties associated with traveling and living in another country. The Student’s level of maturity must be adequate to recognize and cope with these possibilities. Guardian must take responsibility for educating and preparing the Student for the challenges associated with foreign travel and living abroad. Program representatives meet with the Student at least every second month and are available by telephone to provide assistance on an ongoing basis during the Student’s participation in the Program. However, the Program cannot and does not provide constant direct supervision of the Student and Educatius does not act in the capacity of in loco parentis. Guardian retains all rights and duties relating to the welfare of the Student. As a condition of acceptance into the Program, the Participants agree to hold Educatius harmless for all injuries and/or damages incurred during the Student’s participation in the Program resulting from any risks associated with international travel and living abroad, and any negligence and/or intentional acts caused by any third party, including, but not limited to, any member, guest, employee or agent of the Host Family or other persons in the host country.

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H. Health Care Treatment: The Guardian and Student consent and authorize Educatius, or any adult Host Family member to obtain any medical, dental, surgical, psychological, psychiatric or hospital care, deemed necessary by any health care provider, for the health, treatment and care of the Student, provided the necessary healthcare treatment is not associated with a pre-existing condition (prior to Program participation), during Student’s participation in the Program. Any problems arising from inadequate or improper care shall be the responsibility of the health care provider. Educatius shall not be liable for any failure to secure, or the adequacy of, medical attention. The Guardian and Student authorize the health care provider to release the Student to Educatius, or any adult Host Family member. Further, the Guardian and Student authorize the health care provider to release all health care records relating to the Student to Educatius. I/We (Participants) understand and accept that it is my/our (Participants') ultimate responsibility to take any and all steps required with regard to processing and/or payment of any and all medical bills. Pre-existing conditions are not covered by the health insurance provided by Educatius as part of the Program. By signing below, we (Participants) acknowledge, understand, and accept that any pre-existing condition that the Student may have is not covered by insurance provided by Educatius and that any care required for or as a result of such a condition must be paid in full directly by the Guardian. I. Legal Proceedings: The Guardian and Student consent and authorize Educatius or any adult Host Family member to pursue or defend any legal action or proceedings regarding the Student during Student’s participation in the Program in accordance with the natural parents. Any and all legal fees and costs will be the responsibility of the Guardian. Neither Educatius nor any Host Family member shall be obligated or required to pursue or defend any such legal action or proceedings. The Guardian and Student authorize any court, law enforcement agency, or any other government agency to release the Student to Educatius, or any adult Host Family member in the event that the Student is detained or held by any such entity or government agency. J. Use of Student’s Name and Likeness: The Guardian and Student consent to the use of Student’s first name, photograph, film, or video likeness of Student or any comments or statement of Student in materials or publications utilized to promote the Program. Use of Student’s first name and/or likeness shall also be allowed after completion of Student’s Program. Use of Student's first name, likeness, and comments by Educatius in promotional materials will not require compensation by Educatius to the Guardian or Student. K. Rules for Students: The Program Rules for Educatius Students (“the Program Rules”) have been established by Educatius as minimum standards of Participants conduct, and any infraction may result in dismissal from the Program and immediate repatriation (return) of Student to Student's home country at the expense of the Guardian. Each Student and Guardian must acknowledge that they understand and have agreed to adhere to the Program Rules prior to the Student’s final Program acceptance. In addition, Student is required to follow local, state and federal laws as well as school and Host Family rules. Any infraction may result in dismissal from the Program and immediate repatriation of Student to Student's home country at the expense of the Guardian. Educatius reserves the right to, at its sole discretion, amend or change the Program Rules. Participants will primarily be notified of any amendments or changes to the Program Rules through email. Amendments or changes to the Program Rules will be effective immediately upon either: being emailed to Participants or being communicated personally by Educatius, whichever contact occurs first. Participants warrant that they have provided correct email addresses for each individual Guardian and Student in the Student's application and acknowledge a continuing duty to inform Educatius of changes to their provided contact information, including email addresses. Participants also acknowledge a continuing duty to check the provided email addresses on a reasonably frequent basis and respond to emails sent by Educatius promptly, if a response is requested. Educatius shall not be held responsible for any damages or losses caused by Participants' failure to either: inform Educatius of their current email addresses; check their email at reasonably frequent intervals; or respond to emails from Educatius promptly, if a response is requested.

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Educatius is committed to ensuring the safety of the Students. Because of this, Educatius has a zero-tolerance policy for the use and possession of drugs, alcohol, or other intoxicating substances, and/or misuse of legal substances in order to achieve intoxication, and reserves the right to conduct drug testing, at Educatius’ sole discretion, on Student at any time while Student is in the Program. Should Guardian or Student refuse such testing, Student may be dismissed from the Program and repatriated to Student's home country at the expense of the Guardian. Any Student found using, possessing, or handling drugs, alcohol, other intoxicating substances, or related paraphernalia will be dismissed from the Program and repatriated to Student's home country at the expense of the Guardian. L. Problem Notification and Resolution: As the Student is living as a member of a Host Family and not under continual supervision or control of Educatius staff, it is the responsibility of the Student to advise Educatius of any significant problems, including, but not limited to: the health, safety or welfare of the Student, adjustment to school, culture, language, etc. In addition, the Student must notify Educatius of any misunderstandings or problems with the Host Family as soon as possible. Educatius will intervene, if necessary, and attempt to resolve the problem. If necessary, Educatius may, at its sole discretion, seek a replacement Host Family. If the Student violates any terms of this Agreement or the Program Rules, Educatius may, at its sole and absolute discretion, terminate the Student’s participation in the Program and immediately repatriate the Student to Student's home country at the expense of Guardian. M. Agreement between Participants and Sending Organization: Participants understand that Educatius is not a party to any agreement between Participants and the Sending Organization through which the Participants enrolled in the Participants' home country (“Sending Organization”). Participants acknowledge and agree that the laws of their home country shall exclusively govern any dispute or claim arising out of any agreement with the Sending Organization. Participants acknowledge and agree that the Sending Organization is solely responsible to the Participants for injury or damage from a violation of any such agreement. Educatius assumes no duties or responsibilities for any acts or omissions of the Sending Organization. N. Damage Liability Release: If there is damage, as a result of the Participants' behavior, any monetary or other compensation will be paid and satisfied by the Guardian and Student in full, within the time frame given by Educatius or other applicable authority. Educatius or any persons representing Educatius, the Host Family, or the school will, in no way at any point, be held liable for any portion of any financial or other responsibility. O. Refund and fees: If the Student leaves the Program before the end-date of the Program, either by dismissal or by choice, the Participants will not receive a full refund. Educatius retains the right to decide whether any refund will be given to the Participants. The amount of any refund that is given will be determined by Educatius within a time frame given by Educatius and refunded only after the funds have been received from the school by Educatius, if any funds have been received. Any additional fees associated with special classes, clubs or sports that the Student wishes to enroll or participate in shall be paid in full by the Guardian. These costs are not included in the price of the Program and will not be refunded by Educatius. P. General Release, Indemnification and Hold Harmless Provisions: As a condition of Student’s participation in the Program, Participants agree to forever release and hold harmless Educatius for any injury, loss, delay, or any other damage and expense incurred by Participants due to (i) any incident beyond Educatius’ reasonable control, including, without limitation, acts of God, acts of war, or government actions and restrictions; (ii) any events directly or indirectly caused by intentional or negligent acts or omissions by any third party, including but not limited to, any member, guest, employee or agent of the Host Family or other persons in the host country; (iii) risks associated with foreign travel and living abroad, including but not limited to, risks associated with health care services, living

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conditions, sanitation conditions, road and transportation systems, criminal justice systems, civil liberty laws, customs, and values; (iv) any differences in the living conditions and standards between Participants’ home and home country and the Host Family's home and host country; and (v) any act or omission of the Sending Organization. As further condition of Student’s participation in the Program, Participants agree to indemnify and hold harmless Educatius from any liability or expense, including court costs and attorney fees, resulting from any injury, loss or any other damage or expense caused by the Student during Student's participation in the Program. Q. Arbitration and Venue: This Agreement shall be deemed to have been made in the Commonwealth of Massachusetts, USA and its validity, construction, breach, performance and interpretation shall be governed by the laws of the Commonwealth of Massachusetts, USA. The parties to the Agreement acknowledge and agree that any dispute or claim arising out of this Agreement, any resulting or related transaction, or the relationship of the parties, shall be decided by neutral, exclusive and binding arbitration in Suffolk County, Commonwealth of Massachusetts, USA. Either party may appear by telephone at the arbitration hearing. The award of the arbitrator may be enforced in any court of competent jurisdiction located in the USA. In the event that the arbitration clause is deemed void or inapplicable, each party expressly consents to and submits to the personal jurisdiction of the federal or state court(s) of Suffolk County, Commonwealth of Massachusetts, USA. In any action, including arbitration, brought for breach of this agreement, the prevailing party shall be entitled to recover reasonable attorneys’ fees and costs, including but not limited to, the costs of arbitration. The parties agree that any arbitration dispute and any claim that may arise under, or out of, in connection with or relating to this Agreement or any breach hereof, shall remain at all times confidential. R. Authority of Guardian: Each Guardian who signs this Agreement represents and warrants that he or she, together with any other Guardian who signs this Agreement, is the custodial Guardian of the Student and has full authority to sign this Agreement on behalf of the Student as Student's legal guardian without the consent or approval of any other person, and agrees to indemnify and hold Educatius harmless for any liability or expense, including court costs and attorneys’ fees resulting from any breach or claim of this representation. S. Re-Enrollment: If the Participants choose to re-enroll the Student in the same school as identified, suggested, or done previously by Educatius, the Participants agree to do this within Educatius’ Program. The Participants agree to not re-enroll the Student in the same school either directly or indirectly with the school or through another organization without Educatius’ approval, even if the school agrees to directly re-enroll the Student. T. Ratification of Agreement: In the event the Student is under the age of 18 at the time of execution of this Agreement, and the Student attains 18 years of age while participating in the Program, Student agrees that continued participation in the Program after Student attains 18 years of age is deemed a ratification and adoption of all the terms and conditions of this Agreement. U. Educatius Student Enrollment Agreement Controls: Where there are any differences between this Agreement and any other materials related to the Program, this Agreement shall control. Educatius cannot be legally bound or committed by any person other than a fully authorized representative. Parties are required to follow this Agreement and cannot vary from its terms. V. Modification: This Agreement shall not be modified except by a writing that is executed by all the parties hereto. W. Severability: In the event any clause, sentence, term or provision of this Agreement shall be held by any court of competent jurisdiction to be illegal, invalid or unenforceable for any reason, the remaining portions of this Agreement shall remain in full force and effect.

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X. Non-Defamation Acknowledgment: While Educatius encourages Participants to share both positive and negative experiences about their own time in the Program and own experiences with Educatius with any person at any time, Educatius cannot allow Participants to make demonstrably untrue statements that may unfairly damage Educatius' reputation and business or those affiliated with Educatius personally. Participants therefore acknowledge that they have a legal obligation to not make, give, publish, imply, convey, or reconvey any such demonstrably untrue, defamatory, slanderous, or libelous statements in public or private, to the extent allowed by law. Participants also acknowledge a duty to not make any statements that cast any person affiliated with Educatius in a false light. This provision should not be understood as an attempt to limit Participants from making any true statement about their own personal experiences. Y. Acknowledgment of Voluntary Participation and Independent Legal Counsel: Participants acknowledge that they have fully understood this Agreement and enter into it voluntarily, free from any fraud, duress, coercion, pressure, or undue influence from any source at any time. Participants further acknowledge that they have sought and obtained proper clarification, explanation, or translation of any unknown terms, concepts, or language in this Agreement from an independent, qualified legal professional. We, the Participants, have read and fully understand the Program materials and agree to adhere to the Program Rules for Educatius Students and the Educatius Student Enrollment Agreement and Consent Agreements. We further understand that we are obligated to inform Educatius of any significant changes to the Student’s health conditions that may occur after the signature of the Student’s Health Review. Full Name of Student (Please Print) Full Name of Mother/Guardian (Please Print) Signature of Student Date Signature of Mother/Guardian Date

Full Name of Father/Guardian (Please Print) Signature of Father/Guardian Date

PRINT STUDENT’S NAME (FIRST, LAST)

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NATURAL PARENT CONSENT

NATURAL PARENTS CONSENT

I/We understand that while our child, __________________________________________________________________________ , (Print name of child)

is a participant in the Educatius International High School Program, he/she may not pilot any aircraft (including a hang glider) under any circumstances. By signing below, I/we accept full responsibility for our child’s participation in the recreational activities that we specify below; and in consideration of our child’s participation in an Educatius International program, fully indemnify and hold harmless both the US High School attended and our child’s host family from any and all liability, including liability to third parties, that may arise from our child’s participation in the activities specified below. I/we understand that these activities will NOT be covered under the insurance policy that Educatius International will enroll the participant in. I take full responsibility for the additional coverage, or any financial consequences of my child participating.

PLEASE CHECK AND LIST IN WRITING IN THE SPACE PROVIDED WHICH OF THE FOLLOWING ACTIVITIES YOU PERMIT YOUR SON OR DAUGHTER TO PARTICIPATE:

RIDING AS A PASSENGER IN A SMALL PRIVATE AIRPLANE

WHITEWATER RAFTING OR KAYAKING

WATER SKIING

SNOW SKIING OR SNOW BOARDING

HUNTING OR SHOOTING FIREARMS

OTHER HIGH RISK ACTIVITY(IES) (SPECIFY):

If your child wants to participate in high school sports, they may be requested to obtain an additional ”sports physical” before they will be allowed to play. I/we understand that this physical is NOT covered under the insurance policy and will be paid for by the student at the time of the exam.

I/WE PERMIT OUR SON/DAUGHTER TO PARTICIPATE IN HIGH SCHOOL SPORTS ACTIVITIES. NOYES

PARENT OR LEGAL GUARDIAN

SIGNATURE AND NAME OF FATHER OR LEGAL GUARDIAN

TODAY’S DATE (MONTH/DAY/YEAR)

SIGNATURE AND NAME OF MOTHER OR LEGAL GUARDIAN

SIGNATURE AND NAME OF STUDENT APPLICANT

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1) All students must follow the household rules of the Host Family with which they reside. 2) Students are responsible for providing meals for themselves if they choose to eat outside

the host home. This includes school lunches, outings with friends, and similar situations. 3) Educatius has a zero-tolerance policy for any use of alcohol, drugs or other intoxicating

substances and misuse of legal substances in order to achieve intoxication. Students may not buy, sell, possess or use any form of narcotic, alcoholic beverage or controlled substance (unless prescribed by a medical doctor and disclosed previously to Educatius). Students are not allowed to use any legal substance in a way that is meant to achieve intoxication, including but not limited to inhalable intoxicants. This restriction also includes the possession of any drug paraphernalia. Students found to be violating this rule will be dismissed from the Educatius International program immediately.

4) Educatius International does not allow students to smoke tobacco cigarettes, e-cigarettes, or to use any form of tobacco while participating in the Program.

5) Students on the Educatius International Program are not permitted to hitchhike under any circumstances.

6) Students may not make any life-changing decisions while on the program. This includes marriage, changing religion, body piercing and tattoos.

7) Students are not allowed to participate in any sexual contact and other like activities, including but not limited to, sexting, while in the Program.

8) All independent travel apart from Host Family or Natural Family must be approved by Educatius International through submission and approval of a Student Independent Travel Request form. The form should be submitted not less than 14 days prior to the proposed trip. The student must have listed on the form the supervising adult for the duration of the travel and his/her contact information. That adult must be 25 years old or older. The student must receive written approval via the required form from the Natural Family, the Host Family, International Coordinator, and Educatius. Additionally, if the travel will involve absence from school, the school must also approve. Students must not purchase tickets or pay other nonrefundable fees prior to official approval from Educatius. Educatius International will not be responsible for funds lost by students that do not adhere to this process.

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9) Students have the ability to travel and receive visits as long as it does not interfere with academics and school attendance. The Host Family is NOT responsible for handling any travel arrangements for the student or the student’s visitors. Visitors must find a hotel/ motel or other accommodations apart from the Host Family home. The student must coordinate with the Host Family and make sure the Host Family knows the student's location and contact information while the student is traveling or staying with visitors at a location other than the Host Family home.

10) Students must obey the rules and regulations of the high school which they attend. Attendance at school is mandatory. The only exceptions are if the student is ill or has been approved for travel under Program Rule 8. Students are required to enroll in a full course load which includes English. Students are to maintain a minimum of a “C” average (or equivalent if the school uses a non-letter grading system) in each class. Failure to do so, and/or repeated complaints from the school regarding poor attitude or behavior, are grounds for immediate dismissal from the Educatius International Program.

11) The Natural Family and the student must be prepared to accept the Host Family that has been screened and approved by Educatius International Staff. The U.S. is very diverse, and there could be many scenarios.

12) All students are required to participate in the insurance policy provided by Educatius International. Students have the option to purchase additional insurance at their own expense, if desired.

13) Students are prohibited from accepting any form of work or labor in accordance with the rules for the F-1 visa.

14) Students are only permitted to drive motor vehicles during an accredited driver’s education class and only in an authorized driver’s education vehicle. Students are, under no circumstances, allowed to drive any other vehicles, including, but not limited to, the Host Family vehicle. Students are not allowed to purchase or possess any motor vehicle in the U.S.

15) While in the U.S., international students are subject to all local, state, and federal laws. Violation of U.S. law can be grounds for dismissal from the Educatius International Program.

16) Students must follow all rules and decisions made by Educatius International. Educatius reserves the right to terminate a student’s Program should the student violate: the Program Rules; any other guidelines or Program materials issued by Educatius or its partners; any agreements made between Student, the Natural Family, and Educatius; or for other disciplinary reasons.

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STUDENT HEALTH REVIEW, Page 1

TO BE COMPLETED IN BLACK INK, SIGNED, DATED AND STAMPED BY ATTENDING PHYSICIAN

STUDENT’S NAME (AS IT APPEARS IN PASSPORT)

IF ”YES” WAS CHECKED FOR ANY OF THE ABOVE, PHYSICIAN MUST PROVIDE FULL DETAILS:

HAS THE APPLICANT EVER HAD ANY OF THE FOLLOWING?

SCARLET FEVER

MALARIA

CANCER

POLIOMYELITIS

RHEUMATIC FEVER

ENURESIS

COUGH (PERSISTENT)

YES NO

PARASITES

PSYCHOLOGICAL TREATMENT

HEPATITIS A/B

ADHD (ATTENTION-DEFICIT/HYPERACTIVITY DISORDER)

LEARNING/SPEEECH DISORDER

SEIZURE DISORDER

ADD (ATTENTION-DEFICIT DISORDER)

YES NOYES NO

HEADACHE (PERSISTENT)

ALLERGIES TO DRUGS

EATING DISORDER

DIABETES MELLITUS

SLEEPWALKING

ALLERGIES TO FOOD

HERNIA

IF ”YES” WAS CHECKED FOR ANY OF THE ABOVE, PHYSICIAN MUST PROVIDE FULL DETAILS:

HAS APPLICANT EVER BEEN HOSPITALIZED? IF YES, PLEASE EXPLAIN:

HAS APPLICANT EVER BEEN ADVISED TO HAVE SURGERY THAT HAS NOT BEEN DONE? IF YES, PLEASE EXPLAIN:

ANY DISEASE, IMPAIRMENT OR ABNORMALITY OF THE FOLLOWING ORGANS OR SYSTEMS:

DIGESTIVE SYSTEM

VERTIGO, DIZZINESS

TONSILS, NOSE OR THROAT

HEART OR BLOOD VESSELS

EARS OR HEARING

YES NO

BONES, JOINTS, SKELETAL SYSTEM

VARICOSE VEINS

LUNGS, RESPIRATORY SYSTEM

EYES OR VISION

YES NOYES NO

GENITAL-URINARY SYSTEM

ABDOMINAL ORGANS

SKIN (ACNE, ETC)

BRAIN, NERVOUS SYSTEM

BLOOD, ENDOCRINE SYSTEM

YES NO

YES NO

PHYSICIAN’S SIGNATURE DATE (MONTH/DAY/ YEAR) PHYSICIAN’S STAMP

I CERTIFY THAT THE INFORMATION ABOVE IS CORRECT:

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IS APPLICANT PRESENTLY TAKING ANY MEDICATION OR INJECTIONS? IF YES, PLEASE EXPLAIN:

WILL THE APPLICANT BRING ANY REGULARLY USED PRESCRIPTION DRUGS TO THE UNITED STATES? IF YES, WHAT ARE THE NAMES, PURPOSES AND FREQUENCY OF USE OF THESE DRUGS?

YES NO

YES NO

HAS THE APPLICANT EVER CONSULTED WITH OR BEEN TREATED BY A SPECIALIST FOR ANY OF THE FOLLOWING?

ANOREXIA NERVOSA

ATTEMPTED SUICIDE

YES NO

DEPRESSION

OTHER MENTAL DISORDERS

YES NO

BULIMIA

CUTTING OR OTHER FORMSOF SELF-INJURY BEHAVIOR

YES NOYES NO

ALCOHOLISM

SUBSTANCE ABUSE

IF YES, TO ANY OF THE ABOVE PLEASE EXPLAIN:

HEIGHT

BLOOD PRESSURE

WEIGHT

VISION WITHOUT GLASSES: RIGHT EYE OD LEFT EYE OS

VISION WITH GLASSES: OD OS

PLEASE PROVIDE FIGURES FOR THE FOLLOWING:

ARE PUPILLARY AND KNEE REFLEXES NORMAL? IF NO, PLEASE EXPLAIN:

YES NO

DOES THE STUDENT HAVE ANY SCARS OR IDENTIFYING MARKS? IF YES, PLEASE DESCRIBE:

YES NO

ARE THERE ANY RESTRICTIONS ON THE STUDENT’S PARTICIPATION IN PHYSICAL EDUCATION AND/OR SPORTS ACTIVITIES? IF YES, PLEASE DESCRIBE:

YES NO

DETAIL ANY DISEASE, IMPAIRMENT OR ABNORMALITY NOT FULLY EXPLAINED ON EITHER PAGE OF THIS FORM:

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DOES THE STUDENT HAVE ASTHMA? IF YES, PLEASE LIST WHAT MEDICATIONS FOR ASTHMA THE STUDENT TAKE IF ANY:

YES NO

ASTHMAIF THE STUDENT USES AN INHALER FOR ASTHMA OR ALLERGIES PLEASE SUBMIT A SIGNED LETTER FROM THE PHYSICIAN AUTHORIZING THE USE OF THE INHALER ON SCHOOL PROPERTY.

ANY ALLERGIC REACTIONS TO THE FOLLOWING?

SMOKEFOODPOLLENDUST MEDICATIONSMOLDGRASS

FOOD AND OTHER ALLERGIES (PLEASE LIST):

PLEASE DESCRIBE THE STUDENT’S SYMPTOMS:

LIVING CONDITIONS (Please check/mark the appropriate boxes)

CAN ANY OF THE ABOVE ALLERGIC REACTIONS BE LIFE THREATENING? IF YES, PLEASE EXPLAIN:

YES NO

CAN THE SYMPTOMS BE CONTROLLED WITH MEDICATION? IF YES, PLEASE EXPLAIN:

YES NO

NOTE: ANSWERING ”NO” TO EITHER QUESTION ABOVE WILL AUTOMATICALLY MEAN THAT ACCEPTANCE TO THE PROGRAM IS CONDITIONAL AND THAT CHOICE OF SCHOOLS IS LIMITED.

DOES THE STUDENT HAVE ANY ALLERGIC REACTIONS TO THE FOLLOWING?DOES THE STUDENT HAVE ANY ALLERGIC REACTIONS TO THE FOLLOWING?

OTHERSOTHERSBIRDSBIRDSDOGSDOGSCATSCATS RABBITSRABBITSHORSESHORSES

CAN THE STUDENT LIVE IN A HOME WITH A DOG THAT LIVES INDOORS?CAN THE STUDENT LIVE IN A HOME WITH A DOG THAT LIVES INDOORS?

CAN THE STUDENT LIVE IN A HOME WITH A CAT THAT LIVES INDOORS?CAN THE STUDENT LIVE IN A HOME WITH A CAT THAT LIVES INDOORS?

YES NO, DUE TO PET ALLERGYYES NO, DUE TO PET ALLERGY

YESYES NO, DUE TO PET ALLERGYNO, DUE TO PET ALLERGY

ALLERGIESALLERGIESTHIS APPLICATION WILL BE RETURNED AS INCOMPLETE IF PHYSICIAN DOES NOT FULLY COMPLETE THIS PAGE AND PAGE 1 AND 2 PROPERLY.THIS APPLICATION WILL BE RETURNED AS INCOMPLETE IF PHYSICIAN DOES NOT FULLY COMPLETE THIS PAGE AND PAGE 1 AND 2 PROPERLY.

WHAT BREEDS OF DOGS/CATS OR OTHER ANIMAL IS THE STUDENT ALLERGIC TO?WHAT BREEDS OF DOGS/CATS OR OTHER ANIMAL IS THE STUDENT ALLERGIC TO?

CAN ANY OF THE ABOVE ALLERGIC REACTIONS BE LIFE THREATENING? IF YES, PLEASE EXPLAIN:

YES NO

CAN THE SYMPTOMS BE CONTROLLED WITH MEDICATION? IF YES, PLEASE EXPLAIN:

YES NO

IMMUNIZATION RECORD – To be completed by a Physician. Please record all dates with MONTH/DAY/YEAR.

The following immunizations are required for entry into all U.S. schools and the record must be entered on this form. Otherwise, the student will need to receive them in the U.S. at his/her own expense. Individual schools may request additional immunizations at their discretion.

Student Name:__________________________

DOB:__________________________________

City/Country:____________________________

Vaccine (Dates) 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose

DTaP or DTP (child)

Tdap booster (Age 7 or older)

Td vaccine is not enough. Tdap Booster is required.

Polio (a.k.a. TOPV, 4 doses min.)

MMR (if individual vaccines below were not taken)

Measles (a.k.a. Rubeola)

Or Disease Date:

Mumps Or Disease Date:

Rubella (a.k.a. German Measles)

Or Disease Date:

Hepatitis B

Varicella Or Disease Date (Chickenpox):

Meningococcal (a.k.a. MCV4)

BCG (optional)

Tuberculosis (TB) Test Date: ____________________ Result: □ Negative □Positive (Must be within 1 year of program start date, specific states may have different regulations, please check with your advisor) Chest X-Ray/RX: (Required with Positive TB Test (or with TB Test absence)

Date:___________________ Result: □ Negative □ Positive

Physician’s Signature:_____________________ Physician’s Name:________________________

Date: _________________________ Physician’s Seal: :________________________

IMMUNIZATIONS REQUIRED FOR SCHOOL ADMISSION INTO AMERICAN HIGH SCHOOLS – STUDENTS WILL NOT BE ABLE TO ATTEND IF THEY HAVE NOT RECEIVED ALL OF THEIR IMMUNIZATIONS PRIOR TO THE FIRST DAY OF SCHOOL.

1- Diphtheria-Tetanus-Pertussis (DTaP)(DTP): at least 4 doses; one dose must be on or after 4 years of age

2- Tetanus-Diphtheria-acellular-Pertussis (Tdap booster): 1 dose of Tdap for ages 7 through 18; and a recent new one is needed IF 5 years since the last dose.

a. Td vaccine is not enough. Tdap Booster is required.

3- Polio (trivalent Oral-TOPV): 4 Doses, if dose 3 is administered on or after 4 years of age, only 3 doses required.

4- MMR: 2 doses on or after one year of age OR laboratory-confirmed disease verified by a physician. a. Measles (Rubella): 2 doses on or after one year of age OR laboratory-confirmed disease verified

by a physician. b. Mumps: 2 doses on or after one year of age OR laboratory-confirmed disease verified by a

physician. c. Rubella (German measles): 2 doses on or after one year of age OR laboratory-confirmed disease

verified by a physician. d. A 3rd dose might be required if dose #1 was given before more than 4 days before the 1st

birthday

5- Varicella (Chickenpox): 2 doses on or after one year of age OR laboratory-confirmed disease verified by a physician.

a. MMR and Varicella must be given on the same day or at least 28 days apart.

6- Hepatitis B (HEP B): 3 doses – 1st and last dose must be at least 6 months apart.

7- Meningococcal (MCV4): 1 dose at age 11-12 years or older, 2nd dose at age 16 or older. If none was given, at least a recent one is needed.

8- Tuberculosis (TB) Test Date: Must be within 1 year of program start date, specific states may have different regulations requiring TB test pre and post arrival. Please check with your advisor.


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MEDICAL RELEASE AND GUARDIANSHIP FORM

MEDICAL RELEASE AND GUARDIANSHIP FORM

We, _______________________________________________________________, the legal parent(s) or guardian(s) grant Educatius International, its International Coordinators, the school and the host family explicit right in case of an emergency, to authorize medical treatment deemed necessary by a member of the medical profession, in a hospital, medical clinic or doctor’s office, including but not limited to any surgical procedures.

The host family will be the full guardian for, (student name)__________________________________________________________,

The host family will have the right to authorize treatment from a physician for non-emergency conditions as well. In the case that said medical expenses exceed that of the coverage provided by the insurance policy, all of said expenses will be borne by the un-dersigned participant and natural parent or guardian. We will pay all outstanding medical bills as soon as they are brought to our attention.

We give permission to release medical records/information to Educatius International and its representatives.

We confirm at the time of signing this document, our child has perfect health and all health documents submitted are complete and true.

We grant Educatius International, its International Coordinators, and host family permission to represent our child before local or state authorities. If an attorney is required, we will provide all costs and fees necessary to ensure proper representation.

We grant Educatius International, its International Coordinators, and host family permission to allow our child to participate in activities, both school-related and activities outside school, that require guardian’s approval.

We authorize Educatius International permission to access our child’s academic records and request final transcripts.

This document will be valid for the duration of the program, or until the student returns home, whichever occurs first.

STUDENT NAME DATE




SIGNATURE AND NAME OF STUDENT

SIGNATURE AND NAME OF MOTHER OR LEGAL GUARDIAN

SIGNATURE AND NAME OF FATHER OR LEGAL GUARDIAN

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