International Student Application
Student Information
Student Information
Last Name: First Name:
Nick Name: Grade Level to enter:
Date of Birth: (mm/dd/yy) Age: Gender: F M
Address:
City: Province:
Postal Code: Country:
Email: Cell Phone:
Citizenship: Passport Number:
Family Information
Father’s Last Name: First:
Occupation: Lives with student? Yes No
Phone: Email:
Mother’s Last Name: First:
Occupation: Lives with student? Yes No
Phone: Email:
Parents are: Married Separated Divorced Other
Name Gender Age Relationship
Other
Family
F M
Members F M
F M
Emergency Contact
Name one person we can contact if we cannot reach your parents
Name: Phone Number:
Cell Number: Email:
Relationship: Can this person speak English? Yes No
Host Family Placement Information
Religious Affiliation/Denomination:
Religious Participation: Regular Occasional Never
Describe activities at Church you
Faith participate in:
How would you like to continue Very actively Weekly
participation in a church while in the Occasionally Never
U.S.?
Do you have any animals/pets? Yes No
Yes Would you live in a home Yes
Do you like animals/pets?
No with pets? No
Does anyone in your home Yes Would you live in a home Yes
Household
smoke? No with smokers? No
Do you agree not to smoke or drink while attending Jenison High Yes
school? No
Have you ever lived away from your family? Yes No
Check the B for the five words that best describe your family, and check the L for those that least describe your
*Electronic/Typed signatures constitute acceptance of terms stated above
International Student Application
family:
Warm B L Political B L Open B L
Formal B L Religious B L Disciplined B L
Orderly B L Strict B L Inflexible B L
Protective B L Indifferent B L Tolerant B L
Happy B L Demanding B L Intellectual B L
United B L Active B L Informal B L
Serious B L Reserved B L Conservative B L
Student Personality
Check the B for the words that best describe you, and check the L for those that least describe you:
Sociable B L Sensitive B L Warm B L
Serious B L Insecure B L Optimistic B L
Quick-tempered B L Adaptable B L Open B L
Quiet B L Friendly B L Shy B L
Polite B L Spontaneous B L Dependent B L
Responsible B L Mature B L Sense of Humor B L
Neat B L Emotional B L Athletic B L
Student Interests
What do you like to do
in your free time?
What sports or school activities
would you like to participate in?
Use the following code to number only the activities that you are interested in
1 = Currently Active 2 = Would Like to Experience
Computer Museum Swimming Hunting
Photography Poetry Badminton Fishing
Volunteer Work Theatre Volleyball Sailing
Sewing Watching TV Golf Camping
Playing Cards Church Activities Tennis Hiking
Painting Social Dance Football Martial Arts
Gardening Movies Basketball Aerobic Exercise
Indoor Games Woodworking Skiing Weight Lifting
Stage Performance School Club Cycling Gymnastics
Choir Ballet Baseball Concerts
Politics Reading Ice Hockey Cooking
Babysitting Animals/pets Soccer Horseback riding
Listening to Music Arts/Crafts Track&Field Other:
Winter
Music Other
Instruments: Activities:
Type: Sports:
*Electronic/Typed signatures constitute acceptance of terms stated above
International Student Application
Education History
School Currently
City: Grade:
Enrolled In:
Contact person at school: Phone:
Number of years of English Instruction: Proficiency: Average Good Excellent
First Language is: My Second Language Is:
Have you ever been diagnosed with a specific learning disability or ADHD? Yes No
If yes, please explain:
Have you had any behavioral issues (including sexual impropriety) either at school or in the community?
If yes, please
Yes No
Describe:
Have you ever been expelled from a school? Yes No
If yes, please describe:
Have you ever lived or traveled outside your country? Yes No
If yes, please describe:
Education Documents
Please submit the following documents:
Transcripts or certified true copies of report cards from previous two years of education.
English Teacher’s Recommendation (using attached form)
*Electronic/Typed signatures constitute acceptance of terms stated above
