Youth Exchange Program: Parent/Guardian information form (completed by parent/guardian)

Parent/Guardian information form (completed by Parent/Guardian)

Youth Information

Youth's Legal Name(Required)

First Middle Last Suffix

Preferred name or nickname

Date of Birth(Required)

Age(Required)

Gender(Required)

School(Required)

Current grade level(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

1st Parent/Guardian name(Required)

First Middle Last Suffix

Relationship to Student(Required)

1st Parent/Guardian email(Required)

1st Parent/Guardian Cell Phone(Required)

1st Parent/Guardian Home Phone

1st Parent/Guardian Work Phone

Address, if different than above

Street Address Address Line 2 City State ZIP Code

2nd Parent/Guardian name

First Middle Last Suffix

Relationship to Student

2nd Parent/Guardian email

2nd Parent/Guardian Cell Phone

2nd Parent/Guardian Home Phone

2nd Parent/Guardian Work Phone

Address, if different than above

Street Address Address Line 2 City State ZIP Code

Has your child ever broken the law? Breaking the laws of another country can have serious consequences, including imprisonment and (in the case of narcotics offenses in some countries) capital punishment. If yes, please give details.(Required)

Please list all medical and mental health diagnoses, as well as treatment and medication(s). How may they limit your child’s ability to take part in activities, travel, or daily life, especially when on an outbound exchange in another country? Describe any physical and/or mental health accommodations (flexible schedule, assistive technology, medical equipment, mental health support), if any, your child may require to participate in the program? For the outbound exchange, all attempts will be made to match your child to a family who can provide the accommodations, but no guarantee is made.(Required)

Signature of Parent / Legal Guardian (Typed)(Required)

Date(Required)

Youth Exchange Program: Parent/Guardian information form (completed by parent/guardian)

Parent/Guardian information form (completed by Parent/Guardian)

Youth Information

Parent/Guardian Information

Young Global Citizens

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