Student Application

Need to save your progress and return to complete your application at another time?

Please scroll to the bottom of this page and click “Save Application & Continue Later”.
You will be asked to input your email address and you will be sent a link that you can use to retrieve your application within 30 days.

IMPORTANT NOTE: If you refresh this page before saving your progress, your information may be lost. Please save your progress before refreshing.

"*" indicates required fields

Upload Photo of You Here:*

Drop files here or

Accepted file types: jpg, png, Max. file size: 2 MB.

Name*

FIRST NAME (Name as listed on passport) LAST NAME

MIDDLE NAME*

PREFERRED NAME*

GENDER*

BIRTH DATE*

CURRENT GRADE*

GRADE GOING TO*

ETHNICITY*

CITIZENSHIP*

COUNTRY OF LEGAL RESIDENCY*

CONTACT INFORMATION

HOME STREET ADDRESS*

CITY*

PROVINCE/STATE*

POSTAL CODE/ZIP CODE*

COUNTRY*

PREFERRED PHONE NUMBER*

HOME PHONE NUMBER*

MOBILE PHONE NUMBER*

If we want to mail you something, we should send it to:

The Alternate Address listed below

The Home Address listed above

EMAIL ADDRESS*

ALTERNATE ADDRESS (if needed)

RELIGIOUS AFFLIATION (OPTIONAL)

WHAT IS YOUR RELIGIONS, IF ANY?

HOW OFTEN DO YOU PARTICIPATE IN STRUCTURED RELIGIOUS SERVICES?

Bearing in mind that it is likely your host family will have different religious affiliation, how strongly do you feel about having access to structured religious services of your own faith?

Not Necessary

Required

ABOUT YOUR NATURAL FAMILY

WHAT IS YOUR FAMILY STRUCTURE?

PARENT OR GUARDIAN 1

Mother

Father

Other

Do you live with this Parent/Guardian?

Yes

FIRST NAME

LAST NAME

OCCUPATION

EMAIL ADDRESS

WORK PHONE NUMBER

MOBILE PHONE NUMBER

Send a copy of all information to this parent/guardian (select any that apply):

Address

Mailing Address for Parent/Guardian 1

PARENT OR GUARDIAN 2

Father

Mother

Other

Do you live with this Parent/Guardian?

Yes

FIRST NAME

LAST NAME

OCCUPATION

EMAIL ADDRESS

WORK PHONE NUMBER

MOBILE PHONE NUMBER

Send a copy of all information to this parent/guardian (select any that apply):

Address

Mailing Address for Parent/Guardian 2

HOME.INTERNATIONAL NL CONNECTIONS

Has anyone in your family: (if yes, please describe who, the relationship, where and when.)

Participated in an international exchange program

Yes

If yes, what country and what date?

Do you have relatives or close friends living abroad?

Yes

If yes, what country?

Have you participated in any other exchange program, traveled abroad or lived in another country? Please provide details

EDUCATION

CURRENT SCHOOL NAME

CURRENT SCHOOL STREET ADDRESS

CITY

PROVINCE/STATE

POSTAL CODE/ZIP CODE

COUNTRY

PHONE NUMBER

EMAIL ADDRESS OR WEBSITE

CURRENT GRADE/LEVEL

ACADEMIC RECORD/TRANSCRIPT OF GRADES

Attach an official transcript or academic record below

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB.

LANGUAGE

Please provide information about the other languages you speak below

WHAT IS YOUR PRIMARY LANGUAGE?

LANGUAGE 1

HOW MANY YEARS STUDIED?

SPEAKING ABILITY

LANGUAGE 2

HOW MANY YEARS STUDIED?

SPEAKING ABILITY

LANGUAGE 3

HOW MANY YEARS STUDIED?

SPEAKING ABILITY

LANGUAGE 4

HOW MANY YEARS STUDIED?

SPEAKING ABILITY

LANGUAGE 5

HOW MANY YEARS STUDIED?

SPEAKING ABILITY

HEALTH & LIFESTYLE

Do you have physical restrictions, impairments or allergies that will limit placement options or participation in everyday family and/or school activities?

Yes (describe)

Describe any physical restrictions, impairments or allergies

Please check the appropriate boxes if you CANNOT live with:

CATS

Indoors

Outdoors

Why?

DOGS

Indoors

Outdoors

Why?

OTHER

Indoors

Outdoors

Which and Why?

Do you have dietary restrictions (for medical or religious reasons)?

Yes (describe)

Describe any physical restrictions, impairments or allergies

Do you smoke cigarettes?

Yes

If yes in smoking question, please understand that it is illegal in many countries for youth to purchase and/or smoke cigarettes. Additionally, most HomeInternational host families will not accept a participant who smokes.

Yes

LETTER TO HOST FAMILY

Please write a letter of introduction to your host family describing yourself, your family and your hobbies. Attach your document in .PDF format

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB.

PROGRAM PREFERENCE

How did you hear about Home.International NL?

What type of program do you want to participate in?

Full Year (10 Months)

Half Year (5 Months)

When do you want to participate?

YEAR

DEPARTURE PERIOD

Fall (September)

Winter (February)

PASSPORT INFORMATION

NAME OF PASSPORT

PASSPORT NUMBER

PASSPORT ISSUE DATE

PASSPORT EXPIRATION DATE

PLACE OF ISSUE

REMINDER: The name you use in the application needs to be the exact same as in your passport

Upload a Scanned Copy of your Passport in Full Colour

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 2 MB.

EMERGENCY CONTACT

If your Parent/Guardian cannot be reached, please indicate someone else in case of emergency:

NAME

RELATIONSHIP

EMAIL ADDRESS

TELEPHONE NUMBER

HEALTH CERTIFICATE

Please upload medical record from your doctor. Note must not be more than 3 months old.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB.

PARENT STATEMENT

APPLICANT'S NAME

HOME COUNTRY

Please upload a PDF that provides a brief statement about your son/daughter covering his/her:

1. Relationship with you and your family.
2. Relationship with others.
3. Reactions to disagreement and discipline.
4. What is the amount of parental supervision required by your child?
5. How does your child handle challenging or difficult situations?
6. Reactions to being away from home in the past.
7. Please also discuss any factors (eg. dietary. physical, or health limitations) which you believe should be considered in placing your child in a new environment.

UPLOAD YOUR PARENT STATEMENT BELOW

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB.

PARENTAL AUTHORIZATION FORM

APPLICANT'S NAME

HOME COUNTRY

CONSENT

The candidate application, pages 1 to 11, is incorporated herein by reference and this consent form exclusively applies to the candidate application. I understand that my privacy is very important to Home.International NL and that prior to participating in the inquiry application process in which any of my personal or sensitive information (“personal data”) may be collected, Home.International NL would like to inform me about its data protection and privacy policies and obtain my permission.

I understand and accept that Home.International NL may process the personal and sensitive information that I have provided here, and may transmit such data to third parties for any purpose reasonably required for the proper organization and fulfillment of the Home.International NL inquiry application process and the Home.International NL program. I understand that the data will not be sold or otherwise transferred to third parties for purpose. Home.International NL will transfer and store personal data in central databases in at least two locations to ensure that the data is not lost. Currently those locations are in Canada and USA. Those databases have a restrictive access and can only be accessed by Home.International NL employees or volunteers, both of which will use the information exclusively for the management of the Home.International NL program operations.

By signing below, you explicitly acknowledge that Home.International NL., its national and regional affiliates and Partner organizations (herein referred to as “Home.International NL”) are entitled to process the personal data being provided by me (including all sensitive personal data being provided) in the manner described above. You also acknowledge and confirm that all provided personal data is accurate and complete.

PERMISSION TO USE PHOTOGRAPHS AND VIDEO FOOTAGE

We understand that photographs and film and video footage (the images) of current and former candidates are occasionally used by Home.International NL in promotional materials. By signing this Agreement, we grant to Home.International NL the right to use, publish and/or reproduce for any lawful and legitimate purpose excerpts from interviews and letters, images and audio recordings and any other still or moving images of the candidate taken during his/her involvement with Home.International NL and to use his/her name in this connection. We understand that if we do not wish the candidate’s images to be so used, we must mark the following box and initial the space beside it. By leaving this box blank, we understand that we will be deemed to have consented to such use.

Initials

If you initial here, you confirm that you DO NOT give permission for Home.International NL to use such letters, images and audio recordings of your child. In this case, your child may not be allowed to be part of Home.International NL group photos, etc.

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT AND FOR RELEASE OF MEDICAL INFORMATION

Should any medical emergency arise, if time permits, Home.International NL will communicate with us through the custodian and request permission for surgery or other necessary treatment; however, if in the sole judgment of the custodian, time and circumstances do not permit communication with us, we authorize the custodian to consent to medical treatment, the administration of x-ray examination, anesthetics, blood transfusion, medical or surgical diagnosis or treatment and hospital care and to make medical evacuation arrangements and transport, if required, which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon.

We are aware that some local government or school authorities may require certain vaccinations in order for our child to participate in school or community responsibilities. We understand that we are responsible for any costs related to these requirements.

We hereby also authorize Home.International NL, and/or its duly authorized custodian, to obtain all medical records relating to examinations or treatments for our son/daughter while on the program and any other information concerning such examinations or treatments.

PERMISSION FOR SCHOOL SPONSORED ACTIVITIES (FOR SCHOOL-BASED PROGRAMS ONLY)

We authorize the Home.International NL host parents for my son/daughter during his/her participation in the Home.International NL program to execute any authorization required by our son/daughter’s school for our son/daughter to participate in any school sponsored activities, events or programs.

SCHOOL COMMITMENT (FOR SCHOOL-BASED PROGRAMS ONLY)

The student fully understands that this Home.International NL program is school-based and family-oriented. The student intends to participate fully in school activities and to complete all assignments and schoolwork while on program. We understand that school is compulsory. If the student should neglect the above, Home.International NL and/or the host school has the right to deny his/her participation in classes and s/he may be sent home.

APPLICANT'S NAME

APPLICANT'S SIGNATURE

PARENT/GUARDIAN 1 NAME

PARENT/GUARDIAN 1 SIGNATURE

PARENT/GUARDIAN 2 NAME

PARENT/GUARDIAN 2 SIGNATURE

DATE

PLACE

* Parent/Guardian signature is required for all secondary school programs and candidates not of legal age in the country of residence.

Name

This field is for validation purposes and should be left unchanged.

Student Application

Need to save your progress and return to complete your application at another time?

CONTACT INFORMATION

RELIGIOUS AFFLIATION (OPTIONAL)

ABOUT YOUR NATURAL FAMILY

HOME.INTERNATIONAL NL CONNECTIONS

EDUCATION

ACADEMIC RECORD/TRANSCRIPT OF GRADES

LANGUAGE

HEALTH & LIFESTYLE

LETTER TO HOST FAMILY

PROGRAM PREFERENCE

PASSPORT INFORMATION

EMERGENCY CONTACT

HEALTH CERTIFICATE

PARENT STATEMENT

PARENTAL AUTHORIZATION FORM

Information

Services

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