Student Application

Basic Info All answers must be entered in English.

All fields marked with an asterisk (*) are required

First Name*

Last Name*

Gender*

Date of Birth* MM / DD / YYYY

Country of (Legal/Home) Residence*

Country of Citizenship*

Do you have allergies?*

Contact Info All fields marked with an asterisk (*) are required

Home Phone*

Mobile Phone

Email*

Street Address 1*

Street Address 2

City*

Province/State

Country*

Postal Code

About Your Family

To get started, please enter the name and contact information for one parent or guardian. You will have the

opportunity to add another parent (if applicable) and other family members in the main application.

All fields marked with an asterisk (*) are required

Parent First Name*

Parent Last Name*

Gender* Male Female

Email*

Mobile Phone*

Work Phone*

Occupation*

Who do you live with?* Both Parents Father Only Mother Only Other

Your Family Members

Please enter information for all family members you live with, as well as any other legal guardians

Name – Last name E-mail Relationship to You

Academic and Language Skills All fields marked with an asterisk (*) are required

Expected Graduation Date from Secondary School*

Academic years completed by program start date*

Average Grade In All Classes*

Number of Failed Grades*

English Level*

Years of English Study*

Have you been on an exchange program to the U.S. before?* Yes No

Your Program Preferences All fields marked with an asterisk (*) are required

What program are you interested in? * Academic Year Fall Semester Spring Semester

Which academic year would you like to study abroad in? *

Interests and Culture All fields marked with an asterisk (*) are required

Interests - Choose the top three interests or hobbies you enjoy *

Badminton Band or Orchestra Baseball Basketball

Bike Riding Board Games Camping Choir or Singing

Church Activities Community Service Computer / Tech Cooking

Crafting Dance Debating Diving

Drama / Theater Fencing Field Hockey Fishing

Fitness Football Gardening Golf

Gymnastics Handball Hiking Horseback Riding

Ice Hockey Martial Arts Music Painting / Drawing

Photography Playing Cards Politics Reading

Running / Jogging Sailing Scouting Sewing

Skiing / Snowboarding Soccer Sports Swimming

Table Tennis Tennis Travel Visiting Museum

Volleyball Water Polo Wrestling

Choose other interests or hobbies you enjoy *

Badminton Band or Orchestra Baseball Basketball

Bike Riding Board Games Camping Choir or

Singing Church Activities Community Service Computer / Tech Cooking

Crafting Dance Debating Diving

Drama / Theater Fencing Field Hockey Fishing

Fitness Football Gardening Golf

Gymnastics Handball Hiking Horseback Riding

Ice Hockey Martial Arts Music Painting / Drawing

Photography Playing Cards Politics Reading

Running / Jogging Sailing Scouting Sewing

Skiing / Snowboarding Soccer Sports Swimming

Table Tennis Tennis Travel Visiting Museum

Volleyball Water Polo Wrestling

2018 - 2019

Please write up to 3 other interests or hobbies not included in the options above.

Culture

Have you ever travelled outside your country?* Yes No

Please indicate the languages you speak and the number of years you have spoken them.*

Language 1* Year of study

Language 2* Year of study

Language 3 Year of study

What is your religion?*

If you do participate in religious activities, please indicate how frequently.*

Every Day Once per week Once per month Rarely Never

How actively would you like to take part in religious activities with your host family?*

Every Day Once per week Once per month Rarely Never

About Your Home

All fields marked with an asterisk (*) are required

Have you ever lived away from your parents?* Yes No

What are your responsibilities at home?*

Do you have a curfew at home?* Yes No

How much time do you spend studying at home per week?*

Are you willing to live in a home where people smoke?*

Pets

Do you have any pets at home?* Yes No

Are you able to live with pets?* Yes No

Diet

Do you follow a special diet?* Yes No

Are you able to prepare meals for yourself if needed occasionally?* Yes No

Essay Questions

1. Describe in detail an interest or your participation in an activity that you enjoy. What difference has it made in

your life and in the lives of others?

2. What are your future goals?

3. Please write a letter to your host family in English. Do not include your last name, the name of your hometown

or school. This letter will be used by your future host family to help them determine if you are a good match for

their family.

4. Besides learning English, what goals and expectations do you have for your exchange year? What do you think

will be the most challenging part of being an exchange student?

5. Describe an experience you’ve had in the past two years that wasn’t what you expected. What did you do? What

did you learn?

Your Profile Picture

Please send one smiling photo of yourself to ayp1@ieethailand.com under subject “AYUSA Profile Picture:

(Student Name)”. This photo will be your main profile picture.

Identification Document Upload

Please send a copy of your birth certificate and passport. If you do not have passport please send just the birth

certificate.

Your Video

Create and send a video resume for host. This is your opportunity for a family to get to know you, so try to be as

creative and authentic as possible!

Make sure that the final video is at least 1 minute in length and no more than 3 minutes.

Save the video in one of the following file types in CD: mp4, flv ,3gp, avi, divx, mpeg, mpeg2, mxf,

vob, mov ,wmv and ogg.

Send to IEE Thailand

Health Overview

All fields marked with an asterisk (*) are required

Do you have allergies?* Yes No

Do you have any medical conditions or disabilities, mental or physical?* Yes No

Detailed Video Instructions 1. Before You Start

Find a quiet place with good lighting

Dress nicely

Think about answering 2 or 3 of the following questions:

Describe yourself and some of your interests

Tell us about your family members, friends and community

Share one or two cultural traditions in your home country

Why do you want to go to high school in the US and live with an American family?

2. Action!

Maintain eye contact with the camera

Speak slowly and smile

Begin your video by greeting the host family and stating your name, age and your home country

Answer 2 or 3 of the questions listed above

Thank the host family for watching your video and tell them you look forward to hearing from the soon

3. Add More to Your Video

Include clips of yourself engaged in your hobbies, such as playing an instrument, painting, cooking, or playing your favorite sport

Include clips of you with your friends and family

Family and Friends Photo Album

Select 4-8 pictures of you, your family and friends in the places you live or frequently visit, doing the things you

usually do or like to do. Write a brief explanation about each picture, capturing the true spirit of your daily life, in

the description. The album will give your future host family an understanding of your family, home and lifestyle.

Please represent yourself positively and feel free to express your creativity. A minimum of four photographs is

required.

Your Parents' Letter Please write a letter, in English, if possible. This letter should be addressed to the host family who will share their

home with your son or daughter during his/her program.*

Academics Information - List of Recommendation - Please see attach files –

School Recommendation

STUDENT NAME: ____________________________________

1) Has the student skipped or repeated a year? Yes No If yes, please explain why and offer an assessment on the student’s performance since the skipped/repeated year.

2) Does the student have a history of continuous or frequent absences from school? Yes No If yes, please explain.

3) Does the student have any special education needs (i.e. as a result of dyslexia, word blindness)? Yes No If yes, please explain why and outline any special requests that the student may have.

4) Has the student had any adjustment or disciplinary problems at school or in the community? Yes No If yes, please explain.

5) How many total years of schooling, including primary and secondary education, does the student plan to complete prior to university or entrance into the work force? ______________

6) How many of those years will the student have completed by the start of his/her program? ____________

7) By the start of the program, will the student have graduated from secondary school (i.e. completed all schooling s/he plans to complete prior to university or employment)? Yes No If yes, please explain.

School Official Agreement

All of the information I have provided in this section of the Student Application is true and accurate and I have not withheld any information.

_____________________________________________________________________________________________________________________School Official Signature Date

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ENGLISH TEACHER RECOMMENDATION

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Intrax AuPairCare Ayusa World Headquarters | 600 California Street, 10th Floor | San Francisco, CA 94108 | Phone: +1 415.434.1212 | www.ayusa.org

PROGRAM AGREEMENTS

1) Parent Permission to Participate My son/daughter has my permission to apply for, and to participate in, an international study experience sponsored by Ayusa International. 2) Double Placement Agreement Double placements are wonderful opportunities for exchange students because they allow the student to share similar experiences with another exchange student. U.S. Department of State Regulations require prior consent from students and their natural parents if students are double placed. It is the choice of the Student and Parents whether or not to be placed in a Double Placement. Please check one of the boxes below: □ As a Participant, I am open to being placed in a double placement with another Ayusa student. I agree, in advance, to this double placement.

□ As a Participant, I am not willing to be placed in a double placement with another Ayusa student. 3) Single No Children Agreement U.S. Department of State Regulations require prior consent from students and their natural parents if a student is placed in a single parent family with no children living in the home. It is the choice of the Student and Parents whether or not to be placed in a Single No Children placement. Please check one of the boxes below: □ As a Participant, I am open to being placed in a single parent family with no children living in the home. I agree, in advance, to this single no children placement.

□ As a Participant, I am not willing to be placed in a single parent family with no children living in the home. 4) Consent to Take Driver’s Training As the parent of the applying student, I understand Ayusa’s rules regarding driving motor vehicles. I understand that my son or daughter is not guaranteed the right to take driver’s training and that Ayusa students can only take driver’s training if it is in accordance with state laws and/or local school policy. I also understand that many school districts do not allow exchange students to participate in driver’s training. Please check one of the boxes below: □ I give permission to my son/daughter to take Driver’s Training if it is available and if it is in accordance with state laws.

□ I do not give permission to my son/daughter to take Driver’s Training.

Intrax AuPairCare Ayusa World Headquarters | 600 California Street, 10th Floor | San Francisco, CA 94108 | Phone: +1 415.434.1212 | www.ayusa.org

5) Student Smoking/Drinking Agreements As a Participant, I agree not to drink on the Ayusa program. As a Participant, I agree not to smoke on the Ayusa program. 6) Host Family/Community Placement We understand there is no perfect host family or community and are prepared to accept the host family or community that is selected by Ayusa. 7) Program Agreements We have read and fully understand the program materials and agree to adhere to the *Ayusa Rules for Students* and the Ayusa Program Agreement* and Consent Agreements*. We affirm that all the information provided in the student application is true and accurate and that we have not withheld any information. We understand that any failure to disclose information that affects the safety and well-being of the student, as determined by Ayusa, may be grounds for immediate dismissal. ________________________________________________________________________________ Student Name (Printed) Signature Date

Mother/Guardian Name (Printed) Signature Date

Father/Guardian Name (Printed) Signature Date

Intrax AuPairCare Ayusa World Headquarters | 600 California Street, 10th Floor | San Francisco, CA 94108 | Phone: +1 415.434.1212 | www.ayusa.org

Medical Release Authorization I hereby authorize Ayusa, the host parents and the Community Representative, without liability or

expense to themselves, to take whatever action they deem appropriate with regard to my son or

daughter, ___________________________________________‘s, health and safety. They may place my

son or daughter in a hospital for medical services and treatment or, if no hospital is readily available,

may place them in the hands of a local medical doctor for treatment. I also authorize any physician to

release any information acquired in the course of examination or treatment. I understand that I will be

responsible for any costs accrued due to medical treatment that is not covered by the insurance policy.

I certify that the above information is correct to the best of my knowledge. This authorization shall be

valid for the entire duration of the Ayusa program. Please note the Student Application and Admission

Section of the Program Agreement regarding student medical information disclosures.

_________________________________________________________________________________________ Mother/Guardian Name (Printed) Signature Date _________________________________________________________________________________________ Father/Guardian Name (Printed) Signature Date

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DOCTOR'S ASSESSMENT

DTP or DTaP or Tdap (Diptheria, Tetanus, Pertussis) (5 doses. First dose not to be given before 6 weeks of age, 4 weeks between doses 1 & 2 and 4 & 5, 24 weeks between 3 & 4. 1 of the doses must be after 4 years of age.)

Additional Tdap (1 dose of additional Tdap is needed if DTP/DTaP/Tdap was not within last 5 years or is required by school.)

Polio (4 doses, first dose not to be given before 6 weeks of age, 4 weeks between doses 1 & 2 and 6 weeks between doses 2 & 3 and 3 & 4. 1 of the doses must be after 4 years of age.)

Measles (2 doses, first dose not to be given before 12 months of age, min-imum of 4 weeks between doses.)

Rubella (2 doses, first dose not to be given before 12 months of age, minimum of 4 weeks between doses.)

Mumps (2 doses, first dose not to be given before 12 months of age, minimum of 4 weeks between doses.)

Meningococcal Immunization / Date:

Hepatitis A (2 doses, 6 months between dose 1 & 2)

Hepatitis B (3 doses, 4 weeks between dose 1 & 2, and 6 months be-tween doses 2 & 3.)

Varicella/Chicken Pox Previously Contracted / Date: OR 2 doses, first dose not to be given before 12 months of age, minimum of 3 months between doses.

Tuberculosis Negative TB Blood Test* / Date:

* Required within 6 months of program start date, with or without immunization.

Immunization Date (if applicable):

STUDENT NAME: CITIZENSHIP: DATE OF BIRTH:

VACCINE

1ST DD/MM/YY 2ND DD/MM/YY 3RD DD/MM/YY 4TH DD/MM/YY 5TH DD/MM/YY

DATE EACH DOSE WAS GIVEN:

DOCTOR’S ASSESSMENT

IMMUNIZATION RECORD **

CONCLUSION

1) In conclusion, please give your opinion of the general state of the student’s health.

Excellent Good Fair Poor

** Please note that additional immunizations may be required by the state in which the student is placed.

• I have given a thorough physical examinination and reviewed the medical history of the candidate and certify that all important medical information has been included and that the above information is true and accurate.

• I affirm that the patient is stable, both physically and mentally, to participate in an exchange program abroad.

_____________________________________________________________________________________________________________________Physician Name (Please Print) City Country

_____________________________________________________________________________________________________________________Office Phone Fax

_____________________________________________________________________________________________________________________Physician’s Signature (Required) Date