Student Outbound Exchange Application Youth Outbound Exchange: Student Application, Profile, & Agreement Which outbound sister city exchange are you applying for?(Required)Toulon, FranceWilhelmshaven, GermanyBothEitherName(Required) First Middle Last Suffix Preferred name or nicknameSchool(Required)Current Grade Level(Required)Date of Birth(Required) MM slash DD slash YYYY Age(Required)Gender(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Email Student Cell Phone1st Parent/Guardian name(Required) First Middle Last Suffix 1st Parent/Guardian email(Required) 1st Parent/Guardian Cell Phone(Required)2nd Parent/Guardian name First Middle Last Suffix 2nd Parent/Guardian email 2nd Parent/Guardian Cell PhoneStudent QuestionnairePlease give a short self-assessment. Check all that apply.(Required) Sociable Shy Direct Communicative Cool Calm Serious Committed Activities with the whole group preferred Activities in a small group preferred List any volunteer activities, part-time jobs, hobbies, or interests.(Required)What languages do you know and/or have you studied, if any, and for how many years?(Required)What is your previous travel experience (U.S. and abroad), international living, and hosting:(Required)What do you think the benefits and challenges might be living with a host family of a different social or economic standing than you are accustomed to?(Required)Why you want to participate in this exchange? What qualities and characteristics do you feel make you a good candidate to represent Norfolk, VA, USA on this exchange?(Required)Host Family Placement QuestionsReligion (optional; please see participant agreement below)Are you comfortable staying with a host of a different religion?(Required) Yes No If possible, would you prefer to stay with a host of the same religion?(Required) Yes No No Preference Are you comfortable staying with a host who has a pet? Please explain.(Required)Would you prefer a smoking or non-smoking host? Please explain.(Required)If having your own bathroom is not available, are you comfortable sharing a bathroom with your host family?(Required) Yes No What allergies do you have, if any?(Required)What dietary restrictions or preferences do you have, if any?(Required)Are there any physical constraints that should be considered when selecting a host family for you?(Required)What else, if anything, would you like for your host family to know about you?ReferencesCurrent Teacher (must complete the Recommendation form on our website)(Required) First Last Current Teacher's Subject(Required)Current Teacher's Email(Required) Non-relative (must complete the Recommendation form on our website)(Required) First Last Relationship to you(Required)Non-relative's email(Required) Youth Exchange Participant AgreementAs a participant, I am willing to accept that I may be staying with a host family who may be of another race or religious preference, who may not speak my language(s), and who may have customs with which I am unfamiliar. I agree to be respectful of my host family and the accommodations they offer me.(Required) I accept and agree.Basic Policies for Exchange Students1. In the event of an illness or injury, do as your host family advises. If emergency treatment is required, or if you become seriously ill, your parents / guardians will be advised.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.2. Keep your passport in a safe place. Carry it with you only when needed. Make several copies of your passport in the event of theft or loss.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.3. Students are not permitted to drive any motorized vehicle while overseas.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.4. As an exchange student, you may not have paid employment.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.5. While staying with your host family, you will be expected to participate in family life and routine, which could include performing simple household tasks. Be alert to the fact that your host family will have "family rules" by which you are expected to abide and that your host family may have a different approach to young people than does your own family.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.6. During the exchange, you may travel with your host family or on organized group trips. You may not travel alone to distant points unless you have the written permission (prior to the trip) of your parent(s) / guardians and with the consent of your host parents and the prior knowledge of the exchange leader or sister cities leader. Trips should be planned well in advance with definite places of residence. A copy of your itinerary should be left with your host family. Hitchhiking is not allowed.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.7. The drinking of alcohol is forbidden for students during the exchange, except in the case of parental permission by a signed waiver which allows you to drink wine and/or beer in the presence of or at the discretion of your host parent(s). Drugs, other than prescribed medication, are also forbidden.(Required) I have read this rule and agree to abide by it. I understand that failure to do so may result in my being sent home.Signature (Typed)(Required)Please upload a current photo of yourself to share with your host family.(Required)Max. file size: 100 MB.
