HOME COUNTRY MAILING ADDRESSSTREET ADDRESS

CITY COUNTRY POSTAL CODEPROVINCE

ADDRESS IN YORK REGION

STREET ADDRESS

PRIMARY TELEPHONE NUMBER EMAIL ADDRESS

CITY POSTAL CODEPROVINCE

HOST LAST NAME RELATIONSHIP TO STUDENTHOST FIRST NAME

ACCOMMODATION REQUIREMENTS

LOCAL EMERGENCY CONTACTFIRST NAME

PRIMARY TELEPHONE NUMBER

LASTNAME)

IF YES, SELECT A HOMESTAY PROVIDER:

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ESL Sum

mer C

redit

YRDSB-ESL CREDIT 2020

International Summer Programs

(not required if accommodations will be with Homestay Family)

FIRST LANGUAGE

DOB (DD/MM/YEAR)

IMMIGRATION STATUS IN CANADA

/

STUDENT’S PERSONAL INFORMATION

LEVEL OF ENGLISH LANGUAGE

FIRST NAME

EMAIL ADDRESS COUNTRY OF RESIDENCE

FEMALE

OTHER NAME USED

BEGINNER ADVANCEDINTERMEDIATE

36 Regatta AvenueRichmond Hill, ON L4E 4R1 Canada www.yrdsb.ca/international

Telephone: (905) 884 2046 ext237Fax: (905) 727 2406

Email: international.education@yrdsb.ca

PARENT AND FAMILY INFORMATION

PRIMARY TELEPHONE NUMBER (INCLUDE AREA CODE)

MOTHER’S LAST NAME/ FIRST NAME

EMAIL ADDRESS EMAIL ADDRESS

ESL Summer Credit

ASSESSMENT WILL TAKE PLACE ON FIRST DAY OF CLASS TO CONFIRM APPROPRIATE COURSE LEVEL

PROGRAM SELECTIONSTUDENTS WILL BE PLACED IN THEIR 1ST CHOICE. IF UNAVAILABLE WE WILL PLACE STUDENTS IN THEIR 2ND CHOICE, FOLLOWED BY THEIR 3RD CHOICE.

FATHER'S LAST NAME/ FIRST NAME

LAST NAME

PRIMARY TELEPHONE NUMBER (INCLUDE AREA CODE)

1STCHOICE 2ND CHOICE

SCHOOL ATTENDING SEPTEMBER INCLUDING CITY, PROVINCE, COUNTRY

International Education Services

TYPE OF SCHOOL CURRENTLY ATTENDING

Public school in Canada

Private school in Canada

Private/public school outside of Canada

PRESENT GRADE

NAME OF CURRENT SCHOOL, INCLUDING CITY, PROVINCE, COUNTRY ((provide current transcript)

OEN (if attending school in Ontario)

/MALE

EMAIL ADDRESS RELATIONSHIP TO STUDENT

VISIT: WWW.YRDSB.CA/HOMESTAY TO APPLY FOR HOMESTAY FROM ONE OF THESE PROVIDERS

HOMESTAY REQUIRED?

YES NO MLICHN YRDSB

3RD CHOICE

HEALTH INFORMATION

DECLARATION

CUSTODIAN DATE

DATEPARENT

SIGNATURE

SIGNATURE

PAYMENT METHOD

Does your child have an existing medical condition? If yes, please check ( ) the appropriate condition and describe beside checked box(es).

Food Allergy ____________________

Drug Allergy ____________________

Insect Bite Allergy ________________(Carries Epipen)

Diabetic ____________________Epilepsy ____________________Asthma ____________________(Carries Asthma Inhaler)

Injury _____________________Medication _________________Other _____________________(please explain)

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• The registration fee of C$250 is non-refundable in all cases.

• No refund will be granted after the start of the program.

• In the event of cancellation (other than visa refusal) a refund less a cancellation fee (C$250) plus the registration fee (C$250) willbe deducted from the program fee paid. A written cancellation request must be submitted before the May 31.

• In the event of visa denial a refund less the registration fee (C$250) will be deducted from the program fee paid. A copy of the

denial letter issued by IRCC must be forwarded immediately to the York Region District School Board within 30 days of the dateof issue. There will be no refund if the student fails to submit before August 20th.

YES NO

International Summer Programs

AGENT/AGENCY INFORMATION

STREET ADDRESS

TELEPHONE NUMBER (include area code)

FAX NUMBER (include area code)

SIGNATURE

EMAIL ADDRESS

WESTERN UNION BANK DRAFT MONEY ORDER

CITY COUNTRYPROVINCE

AGENCY NAME CONTACT PERSON

DATE (DD/MM/YYYY)

I, the parent of the named child have read, acknowledge and agree that the information given in the application is complete and correct.

Student photographs, video taped images and activities, voice recordings, artwork, writing or other school work may be recorded, displayed or used in board and school specific internet web pages for documentation and presentation purposes of the York Region District School Board. I/We the undersigned, consent to the use of the above noted records and images by the York Region District School Board for the student named below.

I give my child permission to attend school or district-sponsored field trips.

I, the custodial chaperone have shared the above information with the parent/student.

YES NO

YES NO

Personal information is collected pursuant to the education act, as amended, and will be used to assess and document families who wish to be homestay families. Please contact the information access and privacy office for more information about the collection and use of personal information 905 727 0022 x2015 (retained by YRDSB for a period of 12 months from the date of last application).

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ESL Sum

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YRDSB-ESL CREDIT 2020

PARTICIPATIONInternational students must comply with all York Region District School Board policies and the Student Code of Behaviour. Failure to follow school policy will result in withdrawal from the program.

INDEMNITYWe hereby waive, release and absolve and agree to indemnify and save harmless YRDSB, their officers, directors, employees, agents and independent service providers from any and all liability for all the undersigned’s losses and damages (including, but not limited to the loss or theft of the student’s money and the damage, loss or theft of the student’s personal belongings), personal injuries, or death, except such as results solely from its or their willful neglect.

PAYMENT & REFUND

• Registration and payment must be received on or before the May 31st deadline.

• Payment, in full, is required by bank draft or money order payable to York Region District School Board, or by Western UnionGlobal Pay portal (CDN funds).