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IMMACULATA REGIONAL HIGH SCHOOL International Student Program International Student Application for Admittance

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IMMACULATA REGIONAL HIGH SCHOOL International Student Program International Student Application for Admittance IMMACULATA REGIONAL HIGH SCHOOL a member of the Catholic Independent Schools of Nelson Diocese International Student Program International Student Application for Admittance Application for academic year: _____________ Referral Information: Must be completed at time of registration (if applicable) Name: ______________________________ Relationship: ________________________ Agency: _______________________________________________________________________ Student Information Family Name: ________________________ Given Names: ________________________ Canadian Name (if desired): ______________________________________________________ Home Country Address: __________________________________________________________ City: ___________________ Postal Code: _____________ Country: ________________ Home Phone: Country Code ______ City Code ______ Phone # ___________________ Email: ________________________________________________________________________ Gender: Male Female Birth Date: __________________________ Citizenship: __________________________ Language Spoken at Home: _____________ School grade for which applying: 8 9 10 11 12 Program (length of stay) Full school year (September to June) One Semester: September to January February to June Short stay (less than one semester); select month(s) preferred: Sep Oct Nov Dec Jan Feb Mar Apr May Jun If the student intends to stay for longer than one semester, the student should obtain a Study Permit from the Canadian Embassy of the student’s home country. Version 4 (updated May 2021) 2.5 International Student Application Package Page 2 of 22 Father’s Information Family Name: ________________________ Given Name: _________________________ Birthdate: _____________________________________________________________________ Home Address: _________________________________________________________________ City: ___________________ Postal Code: _____________ Country: ________________ Home Phone: Country Code ______ City Code ______ Phone # ___________________ Work Phone: Country Code ______ City Code ______ Phone # ___________________ Citizenship: __________________________ Religion: ____________________________ Occupation: ___________________________________________________________________ Mother’s Information Family Name: ________________________ Given Name: _________________________ Birthdate: _____________________________________________________________________ Home Address: _________________________________________________________________ City: ___________________ Postal Code: _____________ Country: ________________ Home Phone: Country Code ______ City Code ______ Phone # ___________________ Work Phone: Country Code ______ City Code ______ Phone # ___________________ Citizenship: __________________________ Religion: ____________________________ Occupation: ___________________________________________________________________ Sibling Information Name: ___________________________________________________ Age: __________ Name: ___________________________________________________ Age: __________ Name: ___________________________________________________ Age: __________ Is any member of the student’s family a former student of one of the Yes No Catholic Independent Schools of Nelson Diocese? If yes, please note the student’s name and the school attended: _________________________________________________________ 2.5 International Student Application Package Page 3 of 22 Student’s Religious Affiliation Check this box if the student is NOT Catholic. What religious denomination do you practice (if any)? __________________________________ Parish student attends: ________________________________________________ Does the student attend weekly Mass? Yes No Sacraments received (provide the dates and locations) Sacrament Date Location (Parish/City) Baptism Reconciliation First Communion Confirmation Change of Information Please notify the Director of International Education of any change of address, telephone, or e- mail address. 2.5 International Student Application Package Page 4 of 21 Medical Information Physical Condition: Is the student able to participate in a full Physical Education Program? Yes No Emergency and/or Potentially Life-Threatening conditions, please specify: ______________________________________________________________________________ Other symptoms: _____________________________________________________________ Non-Emergency: Physical disability, describe: ____________________________________________________ Other condition, describe: ______________________________________________________ Any condition which might require emergency care, please describe: ______________________________________________________________________________ Does the student require any medical treatment or regular medication? ______________________________________________________________________________ How many times per day? __________________ Schedule: __________________________ Dietary Restrictions: Vegetarian Gluten-Free Vegan Allergies, specify: __________________ No restrictions Likes: ____________________ Dislikes: ___________________________ Please complete Medical Alert Information Questionnaire (Page 15), and attach a copy of the student’s up-to-date vaccination record. All students must register to GuardMe Medical Insurance and, after three (3) months, with the Medical Services Plan of British Columbia (MSP BC) or accepted similar. _____ I understand that in the event of an emergency, the school or homestay family member will send my child to the hospital, and afterwards communicate with the natural parents. Please initial. 2.5 International Student Application Package Page 5 of 22 Academic Information List the last two schools the student attended starting with the most recent. School Grade(s) Location Dates of Attendance Has the student repeated any grades? Yes No If yes, specify the grade(s) __________ and the year(s) __________ Does the student have any academic problems? Yes No If yes, please describe the problem(s). Does the student have or has he/she experienced any social problems? Yes No If yes, please describe the social problems. Has the student had any learning difficulties/disabilities the program Yes No should be aware of? If yes, please specify and attach a report. How long has the student been studying English? _____________________________________ English Competence: Low Intermediate Advanced Fully Fluent Speaking Writing Reading Listening/Comprehension Please attach a copy of the school transcripts, last two (2) report cards, and recommendation letters from the last School Principal and English Teacher of the student. Does the student plan to graduate in British Columbia? Yes No Does the student plan to get the Dogwood Diploma? Yes No 2.5 International Student Application Package Page 6 of 22 International Experience Has the student lived away from home without his/her parents before? Yes No If yes, for how long? _____________________ Where? ______________________________ What kind of trip? School trip Sports team Grandparents/Relatives Other List the student’s interests in sports and other hobbies and activities in which he/she would like to be involved: Soccer Basketball Volleyball Tennis Football Rugby Golf Swimming Hockey Track & Field Skating Ice Skating Biking Hiking Camping Gymnastics Downhill Skiing X-Country Skiing Snowshoeing Working Out at the Gym Others, specify: ___________________________ Hobbies and Activities: Movies Photography Reading Board Games Music Singing Dance Drawing/Painting Sewing/Fashion Crafts Shopping Ceramics/Sculpture Web search/ Video Games Other, specify: __________________________ social media 2.5 International Student Application Package Page 7 of 22 Housing I will reside with my parents/guardian in Canada (Please complete the Guardian’s Information) I require a homestay (Please complete the Homestay Placement section that follows) Guardian’s Information The Legal Guardian is a local contact person responsible for the student while in Canada. Family Name: ________________________ Given Name: _________________________ Home Address: _________________________________________________________________ City: ___________________ Postal Code: _____________ Country: ________________ Home Phone: ________________________ Work Phone: _________________________ Citizenship: __________________________ Religion: ____________________________ Occupation: ___________________________________________________________________ Information for Homestay Placement Household Preferences Two-Parent family, with children: Under age 19 Under age 8 Attending the student’s school Family with no children, older children, and/or grown up children not living at home With pets No pets Pet allergies, specify:_____________ Would you live in a home where somebody smokes? Yes No 2.5 International Student Application Package Page 8 of 22 Homestay Life Please initial beside each statement: _____ CISND manages its own homestay program; it is expected that the student will have full involvement, participation and engagement with the homestay family as part of their cultural/learning experience; and language acquisition. _____ CISND’s homestay program matches students with families based on the information provided on this application form. If a homestay is deemed not suitable, the student can request ONCE to change homestay family. If the second homestay family is deemed not suitable by the student, or by the homestay family’s request (behavior, attitude) the student might be asked to leave the CISND
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