Cultural Exchange Application Form

Highland Secondary School to Verbania, Italy 2024-2025

Image of Verbania, Italy

"*" indicates required fields

Student Information

Name:*

First Last

Gender:*

Male

Female

Neutral

(as identified on passport documents)

Birthdate:*

Age:*

Email*

Phone*

School:*

Current Grade:*

Country of Legal Residence:*

Country of Citizenship:*

Do you have a passport?*

Yes

Not yet, my application is in progress

Passport Expiry Date:*

Note passport must be valid through October 5, 2025. If it is not, please apply for a new passport by Summer 2024.

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian / Parent #1 Information

Name of Parent / Guardian #1*

First Last

Parent/Guardian #1 Email*

Phone:*

Occupation:*

Relationship To Student*

Lives with student:*

Yes

Part-Time

Is Home Address same as students?*

Yes, it's the same

No, it's different

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to add a second Parent/Guardian?*

Yes

Guardian / Parent #2 Information

Name of Parent / Guardian #2*

First Last

Parent/Guardian #2 Email*

Phone:*

Occupation:*

Relationship To Student*

Lives with student:*

Yes

Part-Time

Is Home Address same as students?*

Yes, it's the same

No, it's different

Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hosting Information

While hosting our guests in the Comox Valley, if the student applicant normally spends time each week/ alternate week at different parent’s houses, we ask for the 2 week duration of hosting the student and their buddy remain in one household with one of the parents (for overnight sleeping arrangements)

Please describe all persons living at the same address:*

Full Name

Age

Occupation

Relationship to Exchange Participant

Use the (+) to add more

I understand that each adult (age 18 or over by September 2024) must apply for a criminal record check through the school. Information on applying will be provided to successful exchange applicants.*

I confirm

(some parents may already have this done if they are SD71 employees or have volunteered in other capacities at the school in the previous 2 years. Criminal Record Checks are valid for 3 years.)

Interests & Preferences - To Be Completed By Student

I have a friend who is also applying for the exchange program, their name is

First Last

Select all the activities you enjoy doing*

Describe your Family*

Select all that apply to your family

What kind of pet(s) do you have in your home?*

Cat

Dog

Other

No Pets

How many hours per week do you spend on electronic devices?*

Please enter a number from 0 to 80.

e.g. cell phone, computer, tablet etc.

How many hours per week do you spend watching TV?*

Please enter a number from 0 to 80.

My favourite three classes are...*

If you play a musical instrument - which one?

I can speak the following languages (other than English)

A parent in my household can speak the following languages (other than English)

How do you get to school each day?*

How long does it take? (In minutes)*

Please enter a number from 1 to 120.

My Goal after attending secondary school is:*

(Max 250 Words)

Medical & Dietary Information - To Be Completed By Student & Parent(s)

Medical History

A medical history will not limit your participation, but chaperones need to be fully aware of your medical history and any medications you take regularly. Any medical conditions need to be stable according to the time restrictions/ limitations as stated in medical travel insurance.

History of illness or diagnosed medical conditions for which you may have received treatment - click the check box next to any illnesses you have had:

In the information box below you can elaborate on any illness or injury that is recent or medically managed.

Details of Illness or medical condition/ injury:

If you have had any disease, impairment or abnormality with any of areas listed below, please click the corresponding check box:

Describe any health issue that required medical attention or hospitalization in the last two years:

Please list any preparations / medications that you take on a regular basis, as well as the reason:

List the Foods you like:*

List the Foods you dislike:*

Food allergies or specialized dietary needs:*

Hosting Foreign Students - To Be Completed by Students & Parent(s)

Please describe your home & family- how many bedrooms, house or apartment, will guest student have own room or room share with exchange participant?*

I understand that to participate in the exchange we have the responsibility to host a student in our family and include them in many wonderful family activities and outings, and in return the exchange applicant will live with their buddy’s host family in Italy and enjoy similar hospitality.*

I confirm

I understand it is an expectation of the exchange that we take a break from our extra curricular activities during out hosting 2 weeks in October to focus on our guest buddies and being hosts.*

I confirm

I understand if I am involved in a regularly scheduled activity in October of 2024 (ex. Cadets, robotics, soccer, volleyball, dance, etc) that I will take a break and not attend for the 2 weeks, or, arrange with the activity coordinator for my buddy to come with me and join in on the evening or after school activity. (Please limit your activities, but include your buddy in ones where they will have fun and can join in easily.)*

I confirm

Activities While Hosting Foreign Students - To Be Completed by Students & Parent(s)

While hosting for the two weeks, the student will travel to and from school with their host buddy. The school will arrange a variety of single day field trips, and 1-2 overnight field trips. Other times after school/evening host families are expected to provide a mix of family home time and some excursions out with family/ friends to local venues or activities to help showcase the valley/ island. Families will host students for at least one weekend, and should arrange something nice to do for that weekend.

Check which activities you like to do and you or your family would probably do with your host buddy and some friends perhaps in the evening/ after school/ weekends when they visit in October*

Other Activity Ideas:

Short Note to Exchange Student Buddy - To Be Completed By Student

Please write a short note to your sister school buddy. Describe yourself, what you are interested in, your family, pets, the activities you like to do. Describe your typical school day, evenings and weekends. What has made you interested to be a part of the cultural exchange? Describe some things you are hoping to do in Italy, and some things you hope to do with your host buddy while here.*

(Max 300 words)

Hosting Questions - To Be Completed By Parent

Please describe your home & family - how many bedrooms, house or apartment, will guest student have own room or room share with exchange participant?*

I can volunteer as a parent driver for some field trip activities while we are hosting:*

Yes

Would you be able to host more than one student in the event that we have more students coming over than are going?*

Yes

Parent Confirmations - To Be Completed By Parent

I understand the cost of the exchange (approximate cost may be $4000-$5000), and will be able to make the regular installment payments, including the initial non-refundable deposit of $500 to secure a spot on the exchange if my child is selected to participate.*

I confirm

I also understand the expectations of hosting in October for 2 weeks, and that each parent in the house/ volunteer driver will need to complete the Criminal record check application upon student acceptance into the exchange, and in September of 2024 to complete the volunteer driver forms for school field trips. (Driver abstract, vehicle insurance, photocopy of driver license)*

I confirm

I understand that as a host parent I will be needed to provide transportation to and from school at some adjusted drop off and pick up times due to some arranged field trips needing an early start to the day and evening return times.*

I confirm

I understand that we will provide a safe family home setting with meals and family activities that include our guest student for the 2 weeks, with appropriate guidance and rules in line with school district 71 host family policies. (to be provided and reviewed closer to exchange hosting time).*

I confirm

Fundraising Questions - To Be Completed By Parent

Fundraising for Exchanges is Optional for raising some money toward offsetting individual costs of participating in the exchange.

Please note, there is no guarantee of raising significant funds through fundraising, and it must be parent and student driven. The exchange lead teacher will help facilitate / sponsor some fundraising activities. Parents must have arranged to have full funds organized for the exchange in case fundraising initiative/ interest is low.

I would like to assist with organizing some fundraising activities.*

Yes

No, I'm unable to help

Maybe

I would like my child to do some fundraising and will support them with this*

Yes

No, fundraising is not needed

Maybe

I can volunteer to help as a parent at some fundraisers my child participates in*

Yes

No, fundraising is not needed

Maybe

I have some great fundraising ideas, here they are:

What is a reasonable goal amount you hope your child can fundraise?

Passport Upload

If your passport is valid through October 5, 2024, please upload a scanned colour copy of the ID picture page here:*

Max. file size: 20 MB.

Questions or Comments:

Please review your submission before you hit submit