student application 2008
TRANSCRIPT
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JanuaryAugust
WORLD EXPERIENCE
Teenage Student Exchange
2440 S. Hacienda Blvd., Suite 116
Hacienda Heights, California 91745 USA
RETURN THIS APPLICATION TO:
Please attach
5 RECENT and SMILING photos
in COLOR
PLEASE PRINT IN ENGLISH AND IN BLACK INK
List past or present organizational memberships, positions held, approximate dates:
Organizationsand Clubs(school,
church, farm,civic, sports,social, etc.)
Music and Artistic Interests
WE 8
S L E
(Poor) (Average) (Good) (Excellent)
Sports and Athletics (Poor) (Average) (Good) (Excellent)
Organization Names Posi tions Held ( if any) Yr. to Yr.
Last Name
Eye Color Hair Color SexHeight Weight
One Semester
Program Choice
to
Program Year
Departure
1.
2.
3.
Country Choices: List 3 countries in the order ofyour preference. Do not list states or cities.
Application Date
month day ye
Country
Middle NameFirst Name
Date ofBirth
Academic Year
to
to
to
to
to
to
to
Sport Position Played Level of Skill
List hobbies (exclude sports) and other leisure-time activitiyou enjoy and rate your participation:
(F) Frequent (O) Occasional (P) Periodic F O
month day year
1
STUDENT APPLICATION
Level of Skill
The information in this application will be used to help place you with your hostfamily. Please answer all the questions and rate yourself using the provided scale
Nickname
For Applicants To The USA Only:
Please describe any travel to other countries (including othexchange programs). Where and when did you travel?
Have you previously visited the USA?
If yes, which visa(s) did you use to enter the USA? Pleascheck all that apply:
Yes N
B1/B2 (Tourist) F1 or J1 (Student)
Other:
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List languages other than your native language (P) Poor (F) Fair (G) Good (E) Excellent
EDUCATIONAL BACKGROUND
WE 8
A private school?
A public school?
All applicants must attach school transcripts from the last two years. A transcript from your current year must be brought with you when you arrive in your host coun
Type of course being studied: Total number of students inyour school:
School Currently Attending
Street Address/Route or Box Number
City
State/Providence
Area Code Phone Number
Country Postal Zone
County/District
Academic
Vocational
Commercial
Other (specify):
month day yearSchool year ends__________________ Current Grade Average (GPA)
Grade level to be completed by end of current school year?
2
Ability tounderstand
conversationSpeaking AbilityWriting AbilityReading Ability
LanguageYears oftraining Where learned
P F G E P F G E P F G E P F G E
LANGUAGE ABILITY
Expected date of high school graduation ___________________
month day year Email Address and/or Website
Participation in the World Experience program is primarilyfor the purpose of cultural exchange.
A HIGH SCHOOL DIPLOMA, PARTICIPATION IN GRADUATION CEREMONIES,ATHLETIC PARTICIPATION OR SPECIFIC COURSES CANNOT BE
GUARANTEED.
Opportunities may exist to attend a private school while on the exchangeprogram. Additional tuition charges range from $3000 to $6000. Would you
want to be considered for any placements available at a private school?
Yes No Maybe
To get credit for your semester/year abroad, does your home school haveany specific requirements? If yes, please describe:
PARENT/ GUARDIAN INFORMATION
I live with: Father Step-Father Other
Family Name
First Name Age
Occupation
I live with: Mother Step-Mother Other
Family Name
First Name Age
Occupation
AgeFormer
ExchangeStudent?
AtHome?
Which Countryor State?
Which ExchangeProgram?
YearNames Sex
SIBLING INFORMATION
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First Name Middle NameLast Name
Street Address Apartment Number
CityCounty/District
Country
Email Address
Postal Zone
State/Province
IDENTIFICATION NUMBER:________________(For WE Use Only)
First Name
Employer
Country of Birth
Cell Phone
Family/Last Name
Country of Citizenship
Email Address
Business Phone
STUDENT INFORMATION
PARENT and GUARDIAN INFORMATION
3
Telephone Number
City and Country of Birth Country of Citizenship
Country of Legal Residence Passport Number(if presently known)
Country Issuing Passport Expiration Date (mm/dd/yyyy)
Parent/Guardian #1:
First Name
Employer
Country of Birth
Cell Phone
Family/Last Name
Country of Citizenship
Email Address
Business Phone
Parent/Guardian #2:
Parent That Does Not Live With Me:
First NameLast Name
Street Address Apartment Number
CityCounty/District
Country
Email Address
Home Phone
State/Province
Cell Phone
Country of Birth Country of Citizenship
Occupation Employer
Postal Zone
Business Phone
Age
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IDENTIFICATION NUMBER:________________(For WE Use Only)
PERMISSION FOR MEDICAL CARE AND RELEASE
Please fill in the blanks for an emergency contact other than your parents.
Date Signature of Mother/Guardian Signature of Father/Guardian
We, the applicants parents or legal guardians, agree to authorize World Experience or the host family listed below to act for us in anyemergency, accident, or illness during the periods of time our son/daughter is involved in the program.
We authorize World Experience to submit our son/daughter for the required tests if drug/alcohol use or abuse is seriously suspected.
We understand that World Experience, as part of the program fee, will cover participants in homestay programs with accident andmedical insurance. The insurance will cover the usual, customary, and reasonable expenses incurred by a student up to $50,000, asapproved and recommended by a physician and as listed on the schedule of services shown in the Security Passport for WorldExperience Participants designed by AVI International.
In the event our son/daughter has a reoccurrence of any previous illness or anything contracted before leaving home which is notcovered by World Experience insurance, we authorize WE to release our son/daughter to our personal care. We agree not to holdWorld Experience responsible for any expenses incurred by reason of pre-existing illness and agree to pay for an early return home ofour son/daughter if it is deemed necessary after consultation between WE staff members, designated medical authorities andourselves.
We also agree that any expenses incurred for dental work or eyeglasses, unless resulting from an accident while the student is on theprogram, will become our own personal financial responsibility.
X X
HOST FAMILY
EMERGENCY CONTACT
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Family/LastName of Applicant First Name Middle Name
Street Address
City County/District State/Province
Country Postal Zone Parent Telephone Number
Parent Cell Number Parent Email Address
Parent #1 Family Name/Last Name First Name
Parent #2 Family Name/Last Name First Name
Street Address
City County/District State/Province
Country Postal Zone Telephone Number
Cell Number Email Address
Family/LastName First Name Relationship To You
Street Address
City County/District State/Province
Country Postal Zone Telephone Number
Cell Number Email Address
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EYES
Visual Acuity:Visual Acuity with prescribed glasses:
EARSOtoscopic:
Hearing:
NOSE:
PHARYNX:
NECK
Thyroid:
Glands:
CHEST
Heart:Rate:
Blood Pressure:
Sounds:
Lungs:
ABDOMEN:
EXTREMITIES:
GENITALS:
REFLEXES:
SIGNS OF EMOTIONAL INSTABILITY:
IDENTIFICATION NUMBER:________________(For WE Use Only)
Right Left Type of Test
Right Left
You should not travel before having a dental exam and being sure that all problems are cleared. If you wear braces and will still havethem while overseas, ask your orthodontist to write a letter explaining the corrective system used so that you can give this to an
orthodontist overseas if you need help. The name of the dentist should be printed below and also signed.
ON THE BASIS OF MY EXAMINATION, I HEREBY CERTIFY THAT THE APPLICANT CURRENTLY HAS A HEALTHYDENTAL RECORD AND NO FORESEEABLE DENTAL PROBLEMS.
All spaces should have an entry (such as normal or abnormal). Any abnormalities should be explained seperately. Check that the doctorname and address are printed legibly and that it is signed by the doctor. He/she is responsible for all entries on the Report of Healt
Examination.This includeds sections titled Medical History, Required Immunization Schedule for Schools and Physical Examination.
Please complete all items in ENGLISH.
Name of Dentist (Please Print)
X
Name of Physician (Please Print)
X
Signature of the Dentist
Address:
Address:
City:
City:
State or Country:
State or Country:
Date:
Date:
Telephone:
Telephone:
X
Signature of the Physician
X
II. PHYSICAL EXAMINATION
V. DENTAL EXAMINATION
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On the basis of my examination, I hereby certify that the
applicant is in good health, free from physical or emotionalimpairments, and is able to carry on a full course of study. I
also certify that the information entered in all sections of the
Report of Helath Examination is correct to the best of my
knowledge on the date signed below.
HEIGHT: WEIGHT:
ALLERGIES: Yes No
If yes, please describe the type of allergy and any medications taken:
Does the student take any other medications not already
described? If yes, please identify the medication(s) and the
reason the student is taking them.
Date of last dental exam: Does the student have braces? Yes No
Will the student need orthodontic or other dental care while on the program? Yes No
Please describe:
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Your personal statement should be typed (or written in black ink), single spaced,and composed by you. Please write
this letter using the language of your host country. Discuss the following topics:
1. Describe your family and family relationships. How would your family describe you?2. Describe a school day, vacation day and activities with friends. What activities are important to you?
3. Explain a time in your life when you experienced a challenge. What was the challenge and how did youovercome it?
4. Why do you want to be an exchange student? Why should a host family select you to live with them?5. What are your goals for the future? How will this exchange program help you achieve these goals?
Please use an additional sheet of paper if you need more space.
IDENTIFICATION NUMBER:________________(For WE Use Only)
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LETTER TO HOST FAMILY
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IDENTIFICATION NUMBER:________________(For WE Use Only)
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LETTER FROM THE NATURAL PARENTS
Your son or daughter is about to spend a year or a semester becoming a member of another family. Please
write a letter introducing your family and your child. This letter should be typed or written in black ink.Please write this letter in English or in the language of the host country. Below are some suggested topics:
1. Describe your family and family relationships.2. Describe your childs friends, interests and activities.
3. Explain the character and level of independence of your child.4. Include any additional comments that would be helpful for World Experience or the host family to know about your
child.
Please use an additional sheet of paper if you need more space.
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IDENTIFICATION NUMBER:________________(For WE Use Only)
Please attach a few photos(or color copies) of yourself, your family and your friends. BE CREATIVE!!! Remember todescribe each photo. Feel free to add additional pages, if needed. These photos will not be returned to you.
PHOTO ALBUM
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PLACEMENT INFORMATION AND PREFERENCES
Religious Affiliation (if any):
How often do you participate in religious services?
Weekly Monthly Holy Days Never
Do you smoke? Yes No Sometimes
Are you a vegetarian? Yes No
Do you have other dietary restrictions or allergies?
Yes No
Please explain:
Can you live with pets?Indoors Outdoors None
Please describe any problems living with pets:
How did you hear about World Experience?
Please answer yes or no to the following questions. Try to be open to all host family possibilities. The more times you say
no, the more difficult it will be to place you.
Can you live with:
A single parent A retired/older couple A younger couple
A baby/toddler A pre-teen A teenager No children
Can you live:
On a farm In a rural area In a small town In a city
In a spotless house In a cluttered house
ABOUT ME
Favorite School Subjects:
Favorite Foods & Restaurants:
What I Like To Cook:
Hobbies:
Favorite Authors/Books:
Favorite Music Styles & Singers:
Favorite Movies/TV Programs/Stars:
Some Of My Favorite People Are:
What Bothers Me:
Profession I May Want To Pursue:
I Would Like To Become Better At:
I Would Like To Learn:
What Like Best About Myself:
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DIRECTIONS:
1. List the information for each grade level in each column (grade level, subjects taken, number of hours per week for each subject, andthe final mark). If you are currently in the 9th or 10th grade, you must still include 3 years of grades. This might include your 7thand/ or 8th grade transcripts.
2. This document needs to be reviewed and signed by a school official/counselor or WE director.
Student Name: This school is in session for weeks per year.
ENGLISH
MATHEMATICS
Arithmetic
Geometry
Algebra
Trigonometry
Other:
SCIENCE
Life Science
Physical Science
Earth Science
Chemistry
Physics
Biology
Other:
SOCIAL SCIENCE
History/Native Country
World History
Government
Comparative Gov.
Geography
Sociology
Other
HEALTH
PHYSICAL EDUCATION
FOREIGN LANGUAGE
MUSIC
ART
OTHER SUBJECTS
MARKHPW= Hours Per Week HPW HPW HPW HPWMARK MARK MARK
Name and Signature of School official or WE Director Date
IDENTIFICATION NUMBER:________________(For WE Use Only)
FOREIGN SCHOOL COURSE RECONSTRUCTION FOR WORLD EXPERIENCE STUDENTS
SUBJECT YEAR GRADE YEAR GRADE YEAR GRADE YEAR GRADE
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We agree to the following terms of participation:
1. Our son/daughter has our permission to take part in a program sponsored by World Experience.
2. World Experience will make every effort to find a suitable family for our son/daughter. However, if a family is not found, we will not hold WorldExperience responsible for any arrangements we have or have not made.
3. We have encouraged our son/daughter to prepare well for the intercultural exchange program because we realize this preparation is invaluabletoward making the whole experience successful.
4. We have read the World Experience Code of Conduct included in this application and we will abide by the rules therein. If our son/daughter breaksa rule found in this document, we understand World Experience has the authority to send our child home early and the fees paid will not be refunded.
5. We understand that our child will be treated like a member of the host family and not as a guest. Therefore, he/she will be expected to respect thehost parents, follow the rules of the host family, and accept normal family responsibilities,
6. We will not visit our child without prior permission from World Experience. We understand that permission might not be given. Unless invited by thehost family in writing, we will not expect to stay with them if we come to visit.
7. We understand our child will NOT be allowed to return home for a visit while on the World Experience program.
8. We will limit our communication to one telephone call per month (or on special occasions) and emails once per week. Infractions of these rules canresult in termination of this contract and the student can be removed from the program.
9. Our child will not take a laptop or cell phone to the host country. We understand these items encourage excessive communication with the homecountry. If the student comes with one of these items, they will be taken away from them and returned at the end of the program.
10. We agree to pay for additional tutoring if the school determines our child has insufficient language ability.
11. We understand that our childs personal drinking and smoking habits will be in accordance with my statement on the application, the laws and rulesof my host country, host community, and host family. If it is illegal to smoke or drink alcohol in the host country, we understand our child will be senthome for smoking or drinking alcohol while on the program.
12. We agree to attend all required orientations that may be scheduled before, during, and after our childs participation in this program. Weunderstand our child will be required to attend orientations during his/her stay in the host country.
13. We agree to supply our son/daughter with the amount required for personal spending money and will pay any personal expenses incurred byhim/her while on the World Experience program. The amount required will vary depending on the location of the placement in the host country.
14. We agree that our child will remain in the host country until the completion of the school term. We will not expect him/her to return at ourconvenience but will respect the schedule of the school that has agreed to educate him/her.
15. We have read and understand the following rules concerning the World Experience refund policy:The registration fee is not refundable.The administration fees are not refunded after the receipt of the application and acceptance of the student.The insurance fee is only refundable prior to placement.The national development and international development fees will be refunded on a pro-rated basis, prior to placement only.No fees will be refunded after a student has been placed in the host country.
16. We GIVE DO NOT GIVE permission for World Experience to use our childs photograph for printed or electronic publicity materials.
17. We GIVE DO NOT GIVE permission for our child to attend optional activities/trips that may be organized by World Experience. Wewill not hold World Experience liable for any damages that may result if my child participates in these activities/trips.
Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American
Arbitration Association under its Commercial Arbitration Rules in the state of California, County of Los Angeles, and the judgment on the award ren-dered by the arbitrator(s) may be entered in any court having jurisdiction thereof.
By signing below we certify that we have read the terms stated above and agree to said terms.
PARTICIPATION AGREEMENT
Student Name:
Student Signature: Date:
Parent/Guardian #1 Signature: Date:
Parent/Guardian #2 Signature: Date:
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has listed you as a personal reference for his/her application to be an exchange student
abroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware ofwhen considering him or her.
has listed you as a personal reference for his/her application to be an exchange studentabroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware of
when considering him or her.
has listed you as a personal reference for his/her application to be an exchange studentabroad. Please discuss in writing the following points, as well as any other comments you feel WE should be aware of
when considering him or her.
WORLD EXPERIENCE
2440 S. Hacienda Blvd. Ste. 116Hacienda Heights, CA 91745
WORLD EXPERIENCE
2440 S. Hacienda Blvd. Ste. 116
Hacienda Heights, CA 91745
WORLD EXPERIENCE
2440 S. Hacienda Blvd. Ste. 116
Hacienda Heights, CA 91745
1. In what areas has this student demonstrated above-averagescholastic achievement?
2. In what specific ways has this student shown leadership potential?3. How well does this student relate to peers? To Adults?
1. Describe this students relationships with other members of his/herimmediate family.
2. What personal characteristics does this student have that wouldenable him/her to adjust successfully to living with another familyabroad?
1. Describe the extent of this students involvement in communityactivities.
2. How well does this student relate to peers? To Adults?3. In what specific ways has this student shown leadership potential?
3. Please rate this student on the basis of flexibility, open-mindedness,sense of adventure, sense of humor, friendliness, aggressivenessand active curiosity.
4. How has this student demonstrated maturity, honesty, reliability and/oresponsibility to a degree that would enable him/her to be asuccessful exchange student?
5. Please rate this student on the basis of flexibility, open-mindedness,sense of adventure, sense of humor, friendliness, aggressivenessand active curiosity.
4. Describe this students involvement in extra curricular activities.5. How has this student demonstrated maturity, honesty, reliability
and/or responsibility to a degree that would enable him/her to be asuccessful exchange student?
To the person designated as a SCHOOL REFERENCE:(principal, counselor, or teacher)
To the person designated as a PERSONAL REFERENCE:(a personal acquaintance who knows the applicant well; may not be a relative or an employer)
To the person designated as a COMMUNITY REFERENCE:
(employer, clergyman, neighbor, scout leader, etc.)
PLEASE RETURN THIS WITH YOUR
RECOMMENDATION
CONFIDENTIAL
PLEASE RETURN THIS WITH YOUR
RECOMMENDATION
CONFIDENTIAL
PLEASE RETURN THIS WITH YOURRECOMMENDATION
CONFIDENTIAL
You are required to submit three separate letters of reference foryour application. These must come from three individuals who
are NOT members of your immediate family (household). Theseletters will be held in strictest confidence by WE.
Your SCHOOL REFERENCE should come from a principal,
counselor, or a teacher.
Your PERSONAL REFERENCE should come from a personal
acquaintance who knows you well, but this person may NOT bean employer or relative.
Your COMMUNITY REFERENCE should come from acommunity person who knows you: an employer, clergyman,
neighbor, scout leader or similar individual.
Begin the process of getting your reference letters byobtaining three business sized envelopes. Pre-address and
pre-stamp these for mailing - either to the international office ofWE in Hacienda Heights, California if you are a USA student, or
to the national office of WE in you own country if you are not aresident of the USA.
Note below three coupons, each prepared for a different kind ofrequired reference: School, Personal and Community. On each
of these coupons, in the space provided for the Applicantsname, PRINT your own name. Cut the coupons apart and
attach each to one of the pre-addressed and pre-stamped
envelopes. These envelopes with coupon attached should thenbe hand-delivered to the three individuals who have agreed to
write letter of reference for your application.
PERSONAL REFERENCES