200 Bolinas Road Suite 36,
Fairfax, California 94930
415-509-6757
basil@adventurehomestays.org

INDIVIDUAL STUDENT
SHORT-TERM HOMESTAY ABROAD APPLICATION

**Please use this form to fill in on-line by typing in the fields.

If you have questions, please call us before completing your application - 415-509-6757

Each form must be completed by the appropriate person(s) indicated in the directions at the top of the form. All forms should be completed digitally and saved for your records, or to send partially to get the process going. You will need to send the $350 check by mail, but we begin the process as soon as we receive parts 1, 5, 6, and 7, to expedite the location of the best possible Host Family. This is especially important with "last minute” applications, which we try our best to fulfill. The application should be composed in English, but the Student Letter should be in both English and the destination language. The full application must be returned to Adventure Homestays Abroad with two color photographs (school or passport size) attached in the upper right-hand corner (or as an attached document), a photocopy of your passport, and the $350 non-refundable deposit. Use the checklist at the end of the application to make sure you’ve completed the entire application. Use whatever combination of the above works best for you. Your completed form will be sent via e-mail to us.

To be completed by: Student

Requested Start Date:

Desired Location:

Length of Stay:

STUDENT INFORMATION

Last Name:

(as it appears on passport)

First Name:

(as it appears on passport)

Nickname:

(Optional)

Permanent Address:

City:

State:

City Code:

Current School Website:

Home Phone:

Cell Phone:

Date of birth:

Age at start of program:

Gender:

E-mail Address:

Parent One:

Last Name:

First Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Occupation:

E-mail Address:

Parent Two:

Last Name:

First Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Occupation:

E-mail Address:

Alternate Contact

Last Name:

First Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Siblings

Your ability to speak the target English:

Write a few things about you and your family, including interests and activities?

How do you want to spend your “free” time? Please be specific if you would like to attend a possible day camp (tennis, golf, swimming, dance, Tae Kwon Do, horseback riding, etc.) for an additional expense depending upon the camp. Non-paid internships may be available at no cost. If interested, please let us know in what (legal, farm/ranch, retail, child care, office, camp counselor, etc.)

Describe your community (urban/rural, size, major cities nearby, special attractions, why you like it, etc.).

Add anything you feel will be helpful in selecting a compatible Homestay family. Include whether or not you enjoy young children.

Please note any activity restrictions, special diet, or pet/food/drug allergies.

PLEASE SIGN BELOW

You may sign this application by typing your name(s) and using your mouse, touchpad or finger to draw your signature(s) in the boxes below:

 

Student's Signature:

Date:

Signature of parent #1:

Signature of parent #2:

STUDENT LETTER

DIRECTIONS: Write a letter which will introduce you to your new Host Family. This letter can be completed digitally or hand printed on a separate page. Your Host Family will want to know many things about you: why you want to travel, what you will enjoy doing with them, and the new friends you will make, for instance. Tell them what you are like with your family and friends in the United States; what you like to do, what interests you, what you think about the future. Make your letter as friendly and personal as possible

FAMILY ALBUM

DIRECTIONS: Include photos or send digit photos as attachments to basil@adventurehomestays.org, showing you and your family in the place you live or places you frequently go, doing things you usually do or like to do. This will help your Host Family get to know about you and your family & friends. Please describe your photos.

PHOTOGRAPHY: Photographs are an integral part of the Homestay experience that brings the students’ memories to life for their friends and family back home. The photos are also a testimonial of the student’s lives abroad and are powerful representatives of the Homestay experience. On our website, AHA often posts photos given to us by students, who are excited to share their memories. We would like to continue this tradition so that others may glimpse the experiences of our participants. In order for us to post donated photos, please sign below, granting AHA permission to display photos given to us by the student.

Student Signature:

Date:


Parent Signature:

Date:

PHYSICIAN STATEMENT OF HEALTH

DIRECTIONS: The 2 pages of the health form must be completed by your family physician. It can be completed electronically, printed and signed or printed electronically, completed by hand and signed.

Student Name:

Date of Birth:

Pulse:

Blood Pressure:

Temperature:

Hemoglobin:

Height:

Weight:

Is patient underweight?

Is patient overweight?

Eye examination:

Uncorrected vision:

Right: 20 /

Left: 20 /

 

Corrected vision:

Right: 20 /

Left: 20 /

Eyeglass or Contact Prescription (if applicable):

Rt / V

Lt / V

Urinalysis:

Sugar:

Albumin:

Micro:

Current Medications:

Allergies:
List all allergies to medications, and all other allergies requiring medical treatment upon exposure.

Are there any abnormalities of the following systems? If yes, please attach a written explanation as indicated below.

1. Head, ears, nose, throat:

8. Genitourinary:

2. Teeth, Gums:

9. Muscular / Skeletal:

3. Respiratory:

10. Metabolic / Endocrine:

4. Cardiovascular:

11. Neurological:

5. Gastrointestinal:

12. Psychological :

6. Hernia:

13. Breasts:

7. Eyes:

14. Pelvic:

 

 

15. Skin:

DOCTOR’S COMMENTS: (use additional sheet if necessary):

Do you have a recommendation for physical activity?

Unlimited:

Limited:

Explain:

Do you have recommendations for care of this patient? If yes, please explain.

Is the patient now under treatment for any medical or emotional conditions? If yes, please explain.

Additional comments:

IMMUNIZATION RECORD: (Include all immunizations received since birth.) An accurate and documented record of all immunizations is required.

You may use the form below or attach immunization record.

IMMUNIZATION RECORD

(please record all dates with MONTH/DAY/YEAR)

Student Name (please print):

Date of Birth:

DTP:

Polio:

 

▼ Must be verified with a blood test - attach documentation ▼

MMR:

Date of Disease:

 

Measles:

Date of Disease:

 

Mumps:

Date of Disease:

 

Rubella:

Date of Disease:

 

TB TEST:

Results:

Chest x-ray date:

Results:

If there is a positive test result, a chest x-ray is required. (please attach report)

I give my permission for my son/daughter to receive DTP, Polio, MMR immunizations, a TB test, or a chest x-ray in the Homestay country if deemed necessary.

Parent Signature:

Date:

Physician Name:

Address:

Physician Signature:

Date:

Please send the completed forms to:

Adventure Homestays Abroad
200 Bolinas Road #36
Fairfax, CA 94930
415.509.6757
FAX: 415.785.8534

 

To be completed by:
STUDENT AND PARENTS

CONDITIONS OF TRAVEL

The Price of the Adventure Homestays Abroad program usually covers air fare, ground transportation, health and accident insurance. Please carefully read the details of each AHA program.

The Price does not cover food and lodging prior to departure, baggage insurance, fees for passports or visas, tips, laundry, telephone calls, postage, gifts, beverages and snacks not a customary part of the meals, and any other personal expenses. Each individualized program will have it’s own detail and costs.

AGREEMENT & RULES: Please read carefully and sign below.

1. LAWS: While participating in an AHA Program, student must abide by the local, state, and federal laws of the Host Community abroad. Student must also act within the laws of the United States and the rules of her/ his school. Breaking any law will be cause for immediate dismissal from the program and student will be subject to local law enforcement.

2. DRINKING: In many Europe and other countries, those under 21 years of age may consume alcoholic beverages. AHA students should only drink with their Host Parents, when it is the Host Families choice.

3. DRUGS: The use of all non-prescription drugs is strictly prohibited. Student may use only drugs prescribed by a doctor. (Over-the-counter items like aspirin are permitted.) Involvement with illegal drugs during the AHA Program will cause immediate dismissal from the program.

4. HOST FAMILY RULES: Student must obey Host Family rules including curfews, household chores for which you’re responsible, smoking, and drinking. Student may not have guests in the Host Family’s home without their permission, and the student is expected to follow all family rules. Most Host Families expect their children to inform parents of their plans and time of return home – and expect to be notified if these change.

5. TRAVEL: Student may not travel extended lengths of time without Host Family, Teacher/ Coordinator, or German parents’ permission.

6. DRIVING: While participating in the AHA Program, student will not be allowed to drive under any circumstances. This includes motorcycles and farm equipment. Seat belts must be worn whenever riding in a motor vehicle.

7. TELEPHONE & EMAIL: Cell phone calls, text messaging, and e-mail should be limited to three times during your stay to parents, or for an emergency. You have committed to this program to immerse yourself in the local culture, family life, and the native language. Leave your life back home back home. All phone call and internet expenses will be paid by the participant.

8. VISITORS: Parents and home country friends must receive approval from AHA, host family, and your parents prior to any visit.

9. RETURN HOME: Student must return to the their country at the established AHA departure time. Students must remain in the host-country for the entirety of their Homestay, including major holidays. All changes to departure/arrival dates must be arranged through AHA with parental permission.

We understand that Adventure Homestays Abroad reserves the right to terminate a student’s participation in the program at any time, if in the judgment of AHA a condition arises that is likely to be detrimental to the health or safety of the student or other students – or if the student violates an AHA rule or policy. Adventure Homestays Abroad cannot be held liable, financially or otherwise, for a participant’s withdrawal or dismissal as a result of a pre-existing physical or emotional condition of which we were not made aware. No refunds will be made in such cases – travel expense arising from premature return home from abroad, either alone or accompanied, must be borne by the student.

We understand that Adventure Homestays Abroad (AHA) reserves the right to dismiss or send home any participant whose health, in the opinion of the attending physician, requires this action, or whose conduct, including the use of drugs, unacceptable sexual behavior, drinking, or refusal to comply with Host Family rules, is unacceptable. In the event of dismissal, Adventure Homestays Abroad will be the sole determiner of refund to be made, if any. Refunds will not exceed recoverable costs, and any excess cost will be borne by the student.

We understand and accept the risks of travel and living in a foreign country. We understand that while Adventure Homestays Abroad endeavors to make suitable arrangements for travel and for the Homestay, anything may happen. We are participating because we believe our child is mature enough to cope with everyday situations and whatever unusual situations may arise. As a condition to and as consideration for our child's acceptance in the program, and on behalf of ourselves, children, and relatives, we release Adventure Homestays Abroad, its officers and directors, employees, coordinators, travel agents, and all chaperones, tour guides, schools, international organizations and host families from any liability, claims, or demands that may be asserted in connection with any emergency, accident, illness, or injury involving our daughter/ son’s participation in the program or any cause, event or occurrence beyond the control of AHA - including but not limited to those relating to or connected with natural disasters, civil disturbances, acts of terrorism, negligence of parties not subject to AHA- control. We authorize AHA- and its employees and representatives and adult members of our daughter’s/ son’s host families to act for us in any emergency, accident or illness or injury involving our daughter/ son.

We understand and accept the risks of travel and living in a foreign country. We understand that while Adventure Homestays Abroad endeavors to make suitable arrangements for travel and for the Homestay, anything may happen. We are participating because we believe our child is mature enough to cope with everyday situations and whatever unusual situations may arise. As a condition to and as consideration for our child's acceptance in the program, and on behalf of ourselves, children, and relatives, we release Adventure Homestays Abroad, its officers and directors, employees, coordinators, travel agents, and all chaperones, tour guides, schools, international organizations and host families from any liability, claims, or demands that may be asserted in connection with any emergency, accident, illness, or injury involving our daughter/ son’s participation in the program or any cause, event or occurrence beyond the control of AHA - including but not limited to those relating to or connected with natural disasters, civil disturbances, acts of terrorism, negligence of parties not subject to AHA- control. We authorize AHA- and its employees and representatives and adult members of our daughter’s/ son’s host families to act for us in any emergency, accident or illness or injury involving our daughter/ son.

In case of medical emergency we authorize the Host Family or Adventure Homestays Abroad professionals to make decisions as to treatment or medication. The Host Family and AHA will make every effort to locate and communicate with you concerning an emergency of your son or daughter.

We understand that a student who leaves the program on her/ his own may not expect the assistance of Adventure Homestays Abroad Coordinators. -- and Adventure Homestays Abroad will assume no responsibility for her/ his safety or activities once she/he has separated from the program.

Adventure Homestays Abroad reserve the right to change or substitute, in emergencies or whenever normal circumstances change, any parts of the program when necessary. AHA- also reserves the right to change the cost of the program to meet unexpected changes in transportation, lodging, or exchange rates.

We have read this Agreement and agree with the AHA purposes and accept all terms and conditions of this agreement - and all other rules, regulations and conditions set forth by AHA.

Student Signature:

Date:

1st Parent Signature:

Date:


2nd Parent Signature:

Date:

APPLICATION CHECK LIST

DIRECTIONS: This application packet includes 7 separate items. Each form is listed below along with the person(s) responsible for its completion. Use this check list to ensure all materials are completed and enclosed. (Remember to keep a copy of the Agreement & Rules.) Please return completed application materials to:

Adventure Homestays Abroad
200 Bolinas Road #36
Fairfax, CA 94930
415.509.6757
Fax: 415-785-8534

FORM TO BE COMPLETED BY "✔" WHEN COMPLETED
1.   STUDENT INFORMATION STUDENT
2.   STUDENT LETTER STUDENT
3.   FAMILY ALBUM STUDENT
4.   HEALTH RECORD & PHYSICAL EXAMINATON FORM STUDENT / PARENT / PHYSICIAN
5.   AHA STUDENT RULES & AGREEMENT STUDENT / PARENT / PHYSICIAN
6.   PHOTOCOPY OF PASSPORT AND 2 PASSPORT SIZE PHOTOS STUDENT
7.   $350 NON-REFUNDABLE DEPOSIT STUDENT & PARENTS

Please send Parts1, 5, 6 and 7 ( your Student Information, a copy of your passport, two passport size photos, and the signed AHA Student Rules and Agreement )with your deposit to begin the process of locating the best possible Host Family and School (if included) for you. Your Letter, Family Album and Health Record/ Physical Exam should follow as soon as possible.

PLEASE KEEP THIS FORM FOR YOUR RECORDS

Payment Schedule

With submission of application: $350 deposit (non-refundable) Remainder of total cost:

  • ▪ Payments are usually divided into three equal amounts with the last payment due six weeks before departure.
  • ▪ Please make all checks payable to Adventure Homestays Abroad
  • ▪ A $25 penalty will be charged for any returned checks
  • ▪ Prices based on current exchange rates and may be subject to change Refund policy There will be no refund after the final payment is made.

Please send this deposit slip with your $350 check to:

Adventure Homestays Abroad,
200 Bolinas Road #36
Fairfax, CA 94930

415-509-6757 • Fax: 415-785-8534

Name:

Phone:

Date of Birth:

Address:

City:

State:

Zip:

Student Signature:

Date:

Parent / Guardian Signature:

Date:

 

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