COPY OF PASSPORT Standardized English Test Results. IELTS ... · IELTS Equivalent Score of 4.5...

Mission International Student Program - Application Package of 12

International Student Program

33046 Fourth Avenue, Mission, BC V2V 1S5 CANADA

Tel: 604-826-6286 Fax: 604-820-2335

International Program Office: [email protected]

INTERNATIONAL STUDENT PROGRAM – APPLICATION PACKAGE

Mission Public School District invites applications to our International Student Program

Notification All applications will be acknowledged, and applicants will receive a Conditional Offer of Acceptance

when they have been offered placement in our program.

Letter of Acceptance (LOA) and Study Permit Application:

The official LOA can only be issued once we receive full payment of fees. The LOA is required for the student to apply for their Study Permit at the nearest Canadian Immigration Office.

Application package must include:

COPY OF PASSPORT Completed application form including immunization records

Original Copies + Translated Transcript of grades (in English) from current school year and 2 previous school years

Recent photograph attached to application

Standardized English Test Results. IELTS Equivalent Score of 4.5 Required for Enrollment in High School Credit Courses.

For which program are you applying? B.C. Graduation OR English / Cultural Immersion Program

Full Academic Year (September – June)

Semester 1 (September – January)

Semester 2 (February – June)

Other (please specify dates) ______________________________________________________________________________________

Circle the grade you wish to attend in Mission Public Schools: Elementary: _______ 4 5 6 Middle: 7 8 9 Secondary: 10 11 12

Our Program Staff Will Determine Appropriate School Placement Based on Information Provided in This Application

Agency Information Referring Agency: _________________________________________ Agency Representative: ________________________________________ Address: ________________________________________________________________________________________________________________ Phone: __________________________________________________ Fax:________________________________________________________

Country Code Area Code Phone No. Country Code Area Code Fax No.

E-Mail:

Please read carefully and complete all sections clearly.

1. Student Information: PLEASE PRINT IN ENGLISH Date of Application:

Student Family Name: __________________________________________ Student Given Name(s): _______________________________________

Date of Birth: __________________________ Age: _____ Gender: ___ Male ___ Female

Day / Month / Year

Country of Birth: ____________________________ Citizenship: __________________________ Passport Number: ________________________

My first language is: _____________________________________________ Second language: _______________________________________

Permanent Address

Street Address

_____________________________________________________________________________________________________ City Province/State Country Postal Code

Home Phone: _____________________________________________ E-Mail: _____________________________________________________ Country Code Area Code Phone No.

Please Attach

Student Photo Here


2. Family Information (INCLUDE COPY OF PARENTS PASSPORTS) STUDENT LIVES WITH _______ Both Parents ________ Father Only ________ Mother Only

Father: __________________________________________________ Mother: _____________________________________________________ Surname Given Name Surname Given Name Father’s date of birth: _______________________________________ Mother’s date of birth: _________________________________________ Day / Month / Year Day / Month / Year Parent’s Email: ____________________________________________________________________________________________________________

Brothers: _______________________________________ _______ ________________________________________ _______ Name Age Name Age Sisters: _________________________________________ _______ ________________________________________ _______ Name Age Name Age Circle the five words that best describes your family, and underline those that least describes your family:

warm strict formal informal orderly reserved conservative

serious demanding happy active united indifferent tolerant

protective open political disciplined religious inflexible intellectual

3. Emergency Information (to be completed by parent)

In an emergency, we may need to contact you quickly. Please give detailed information for one other person we can contact if we cannot reach you.

Name

Relationship

Phone #

E-mail

Can this person speak English? Yes ____ No ____

4. Educational History

I enclosed transcripts or certified true copies of report cards from my previous two years of education in my home country.

I am currently enrolled in grade ______ at _________________________________________(school name) in __________________________(city)

I would describe my ability in the use of the English language as: Beginner Intermediate Fluent Number of years of English instruction: _______

5. Behavioral and Medical History

Have you been convicted of a criminal offence: Yes ______ No ______

If yes, please describe in detail: ______________________________________________________________________________________ ________________________________________________________________________________________________________________ Have you ever been diagnosed with a specific learning disability or ADHD? Yes ______ No ______ If yes, please explain:

Have you had any behavioral issues (which include sexual impropriety) either at school or in the community: Yes _______ No _______ If yes, please describe in detail: ______________________________________________________________________________________ ________________________________________________________________________________________________________________

Smoking: Do you smoke? Yes ______ No ______ If yes, are you willing to stop if the family requires it?Yes ______ No ______ Allergies: Does the student have any allergies: Yes _____ No _____ If yes, please describe allergy and current medication, if applicable: __________________________________________________________ ________________________________________________________________________________________________________________ Are you allergic to some pets? Please list all ____________________________________________________________________________________


Immunization History Please indicate the dates when your child received the following immunizations.

1

st dose

day/month/year

2nd

dose day/month/year

(If Applicable)

3rd

dose day/month/year

(If Applicable)

4th dose

day/month/year (If Applicable)

5th dose

day/month/year (If Applicable)

TETANUS

DIPHTHERIA

PERTUSSIS (Whooping Cough)

POLIO

HAEMOPHILUS INFLUENZAE type B

MEASLES (Rubeola)

MUMPS

RUBELLA (German Measles)

HEPATITIS B

VARICELLA (Chickenpox)

MENINGOCOCCAL C

PNEUMOCOCCAL

OTHER:

History of Illness: Have you had any of the following illnesses/conditions?

Any disease, impairment or abnormality of:

Yes No Yes No

Blood or Endocrine System Lungs, Respiratory System

Bones or Joints Other Abdominal Organs

Brain or Nervous System Personality/Behavior

Ears or Hearing Skin (Acne, Eczema, etc.)

Eyes or sight Stomach/Digestive System

Genito-Urinary System Tonsils, Nose or Throat

Heart and Blood Vessels Have Tonsils been removed

Give a full description of any health issue mentioned that required medical attention in the last two year period: ________________________________

________________________________________________________________________________________________________________________

List any preparations/medications that you take on a regular basis and the reason: ______________________________________________________

________________________________________________________________________________________________________________________

Have you had any treatment/counseling for emotional and/or psychiatric problems: Yes ____ No ____

If yes, please describe in detail:_________________________________________________________________________________________

__________________________________________________________________________________________________________________

Have you ever been diagnosed with anorexia or bulimia: Yes ____ No ____

If yes, please describe in detail:_________________________________________________________________________________________

__________________________________________________________________________________________________________________

6. Student Interests Foods: I like ____________________________________________ I don’t like ___________________________________________________ Please describe any food allergies or specialized dietary needs: (eg: Vegetarian) _____________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Yes No

Allergies

Appendicitis

Appendix removed

Asthma

Chicken Pox

Diabetes

Diphtheria

Epilepsy

Hepatitis -any form

Hernia operation

Malaria

Measles

Mumps

Yes No

Parasites

Pneumonia

Polio

Rheumatic Fever

Rubella

Scarlet Fever

Serious Cough

Headaches/Migraines

Smallpox

Tuberculosis

Typhoid

Vertigo/Dizziness

Other diseases


Please number, in order of preference, the five activities you enjoy the most, from the following:

____ reading _____ surfing ____ skiing ____ listening to music

___ arts/crafts _____ water skiing ____ painting, drawing ____ camping

_____ theatre _____ attending concerts ____ volleyball ____ martial arts

_____ movies _____ wrestling ____ ballet ____ visiting museums

_____ drama _____ modern dancing ____ fishing ____ playing individual sports

_____ golf _____ snowboarding ____ watching sports ____ soccer

_____ cooking _____ chess ____ gymnastics ____ playing team sports

_____ playing cards _____ basketball ____ bicycling ____ tennis, table tennis

_____ rugby _____ American football ____ hiking, backpacking ____ baseball

_____ photography _____ sailing

_____ participating in social clubs / school clubs / political clubs / religious clubs

_____ collecting (name one or two)

_____ singing in an organized group

_____ playing a musical instrument. If so, which instrument? ________________________________________________________________

_____ other: _______________________________________________________________________________________________________

How many hours per week do you spend watching T.V.? _______ How many hours per week do you spend on the computer for entertainment? _______

Check the two items that are your most important reasons for participating in this program:

Obtain a Canadian education Participate in high school athletics Become more independent and mature

Pursue a personal interest or hobby Teach others about my own country

How actively would you like to pursue your religion while in Canada?

Very actively Weekly Occasionally Never I learned of the Mission Public Schools International Student Program through:

Friend/Relative Where? In home country In Canada Internet

Newspaper/Magazine article: Name of publication: _____________________________________________________________________________________________

International student program recruiting fair: Location: ____________________________________________________________________ Recruiting agent: Name of agency: ____________________________________________________________________________________

7. Homestay Information

Homestay Preferences (please circle):

Please write some information about yourself and include photos of you with family and friends to help us select a homestay family for you.

*Please attach additional sheets with photos and write-up.

Would you prefer a family with:

Young children?

Teenagers?

YES

YES

NO

NO

Are you comfortable living with a Single parent?

Another international student?

YES

YES

NO

NO

A dog? YES NO

A cat? YES NO


International Student Program Course Request Sheet

Must Be Completed by Grade 10 – 12 Students

Student Name: Grade in Canada: ________________ Graduation Program: YES / NO

Note: There are occasions when classes are not offered or are full.

Select at least 12 courses if you are studying here for the year.

Select at least 8 courses if you are studying here for one semester.

Students requiring ESL/ELL support will have their schedule adjusted to ensure that their English level is adequate for requested/required courses.

Please remember to include your Standardized English Test Results with your application. A minimum IELTS Equivalent Score of 4.5 is required for enrollment in High School Credit Courses. A. Required Academic Courses for Graduation:

Grade 10: English Math PE Science Social Studies Planning 10 / Career Education 11

Grade 11-12: English Math: Foundations of Mathematics 11 Pre-Calculus 11 or 12 Calculus 12 (+AP)

Apprenticeship /Workplace Math

(1 or more Sciences for Grad Program) Science: Biology 11 or 12 (+AP) Chemistry 11 or 12 (+AP) Physics 11 or 12 (+AP)

Earth Science 11 Science & Tech 11

Socials: Social Studies 11 (To complete the BC Graduation Program)

Career Education: Post Secondary Career Prep 11/12 or Graduation Transition Plan 12

B. Elective Courses: Choose at least 5 or more courses from the Elective Courses below.

Please number your choices in order of preference (1st choice = 1; 2

nd choice = 2; 3

rd choice = 3; 4

th choice = 4, 5

th choice = 5, etc.)

MUSIC AND ATHLETICS PROGRAMS

3-D Printing 11-12

Foods 10-12

May take place before or after school:

Aboriginal Studies 10-12 Genocide Studies 12

Band - Jumpstart 10-12

Accounting 11-12 Geography 12 Band: Concert/Jazz 10-12

Animation 10-12 Geology 12 Your Instrument:____________________

Art Foundations 11-12 Global Education 10-12 Choir – Concert / Vocal Jazz 10-12

Athletic Injuries 11 History 12 Guitar 10-12

Athletic Leadership 10-12 Interior Design 11-12 History of Rock & Roll 12

Automotive Technology 11-12 Law 12 Musical Theatre 10-12

BC First Nations 12 Leadership 10-12 Theatre Company/Production 10-12

Business Law 12 Marine Biology 11 ATHLETICS

Cafeteria Training 10-12 Marketing 11-12 Community Recreation 10-12

Ceramics & Sculpture 11-12 Metal Work/Fabrication 10-12 Basketball Sports Specific 10-12

Comparative Civilizations 12 Peer Tutoring 11-12 Football Sports Specific 10-12

Computer Game Development 11-12 Physical & Health Ed: Girls 10-12 Hockey Academy 10-12

Contemporary Indigenous Studies Physical & Health Education 10-12 Lacrosse Academy 10-12

Criminology 12 Power Technology 10 Rugby Sports Specific 10-12

Dance Company/Performance 10-12 Print Making/Graphic Design 11-12 Volleyball Leadership 10-12

Drafting 10 Psychology 11-12 (+AP) LANGUAGES:

Drama 10 / Acting 11-12 Robot Construction 12 ESL/English Language Learners

Drawing & Painting 10-12 Robotics 11-12 French Immersion / Fr. Langue 10-12

Economics 12 Skills Explorations 11 French 10-12

Engineering & Design 10 Social Justice 12 Japanese 10-12

English Composition 10 Strength Training 10-12 Spanish 10-12 (+AP)

English Creative Writing 10 Strength Training: Girls 10-12 ADVANCE PLACEMENT COURSES:

English First Peoples 10-12 Textiles/Sewing 10-12 AP Biology 12

English Literary Studies 10 Visual Arts 10 AP Calculus 12

English New Media 10 Web Design/Development 10-11 AP Chemistry 12

English Spoken Language 10 Woodwork/Carpentry & Joinery 10-12 AP English Language & Composition 12

Entrepreneurship & Marketing 10 Work Experience 12 AP English Literature & Composition 12

Entrepreneurship 12 Writing & Journalism 12 AP European History 12

Environmental Studies 12 Yearbook 10-12 AP Psychology 12

Family Studies 11-12 Youth Work in Trades 11-12 AP Spanish 12

Fashion Design 12

AP Statistics 12

AP Studio Art 12


International Student Program Course Request Sheet

Must Be Completed by Grade 7, 8, 9 Students

Student Name: Grade: Preferred School Name: __________________________________ Graduation Program: YES NO

Note:

1. Students requiring ESL/ELL (support for English Language Learners) will have their schedule adjusted to ensure that their

English level is adequate to cope with the demands of requested/required courses.

2. There are occasions when classes are not offered or are full. Please choose additional courses in case your first choice is not

available.

A. Required Academic Courses:

Grade 7, 8: English Math PE (Health & Career Ed) Science Socials Studies French

Explorations Rotation ______ or Band / Choir ______

Explorations Rotation: Students sample a variety of Applied Skills and Fine Arts courses.

Grade 9: English Math PE Science Socials Studies Health & Career Education 9

ALSO: Choose at least 5 or more Elective Courses from the list below:

B. Elective Courses:

Please number in order of preference (1st choice = 1; 2

nd choice = 2; 3

rd choice = 3; 4

th choice = 4, 5

th choice = 5, etc.)

Art ESL / ELL for English Language Learners

Band - Concert Band French

Band - Jazz Band French Immersion

Business Education (9) Spanish

Cafeteria (9)

Choir

Information and Communication Technology

Cooking

These courses may take place outside regular

Dance (9)

school hours (before or after school):

Digital Literacy

Drama

Jazz Band

Drawing & Painting

Musical Theatre

Robotics and Drafting (9)

Leadership

Foods

Metalwork

Power Technology (9)

Hatzic Hockey Academy

Sewing/Textiles

Hatzic Volleyball Leadership

Webpage Design

Basketball

Woodworking

Soccer

Yearbook


International Student Program

33046 Fourth Avenue, Mission, BC V2V 1S5 CANADA

Tel: 604-826-6286 Fax: 604-820-2335

INTERNATIONAL STUDENT PROGRAM – AGREEMENTS & WAIVERS

PARENT OBLIGATIONS

1. I/We give permission for my/our child to take part in all programs sponsored by the Mission Public School District #75 International Student

Program. This includes school field trips and recreational activities organized by the International Program staff. 2. In case of serious infractions of program rules as outlined in the Student Agreement for Mission Public School District #75 International Student

Program, I/We understand that my/our child may be required to return home. In this situation, I/We understand that there will be no refund of program fees and that I/We will be financially responsible for my/our child’s return home.

3. I/We agree, should it become necessary, to the return home of my/our son/daughter for serious medical reasons. In this case, I/We understand

that I/We am responsible for travel expenses. 4. I/We will discuss with my/our son/daughter, the responsibilities of an International student as outlined in the Student Agreement for the Mission

Public School District #75 International Student Program. 5. I/We understand that Canada is a multi-cultural country and that customs and traditions of families may be different from my/our own. I/We

understand that discrimination, based on race, philosophy, or religion is illegal in Canada. 6. I/We understand that my/our child will be assessed by program staff for English language competency and placed in a suitable program. This may

include ESL classes. I/We agree that my/our child will remain in ESL until the teaching staff feel that he/she is ready for regular programming. 7. I/We understand that although Canada and its communities are very safe by world standards, and that my/our child will be generally supervised

both at school and by the homestay family, such supervision will not be constant and the child’s constant safety cannot be guaranteed. 8. I/We hereby waive and release and absolve and agree to indemnify and save harmless Mission Public School District #75, the Host Family, and all

Program employees, from all liability arising from my/our child’s participation in the Mission Public School District #75 International Student Program.

9. I/We permit Mission Public School District #75 to use photographs or images of my/our child in promotional materials. This may include but is not

limited to pictures published on the International Program or Mission Public School district websites, print materials, marketing videos, newsletters, school yearbooks, or online on the social media profiles of Mission Public Schools International Student Program.

10. I/We give permission for my/our child to participate in travel to the USA or other Canadian provinces with an approved host family or International

Student Program Staff provided that adequate medical insurance is in place. I/We agree that my/our child will return home promptly after their program end date. I/We understand that any extension of stay beyond the program end date must be approved in advance by the Mission International Student Program. I/We agree to provide all details of any plans to extend beyond the program end date. I/we will obtain approval from the Mission International Student Program, and provide appropriate signed release waivers well in advance of the program end date. ADDITIONAL HOMESTAY FEES WILL APPLY. I/we, as parents/guardians of the undersigned student, do hereby confirm that I/we have reviewed with my/our child the terms and conditions of this agreement which my/our child has signed and agreed to honour, and I/we agree that my/our child and I/we shall be bound by all the terms of this agreement.

I/we, as parents/guardians understand that having signed this agreement, failure of my/our student to follow the above rules could result in disciplinary action and/or immediate dismissal from the Mission Public School District #75 International Student Program. Should it be necessary to send my/our student home, I/we understand that the Canadian Immigration Consulate will be notified immediately.

Name of Student

Name of Parent/Legal Guardian 1 Name of Parent/Legal Guardian 2

Signature of Parent /Legal Guardian 1 Signature of Parent/Legal Guardian 2

Date Date


STUDENT/PARENT PARTICIPATION AGREEMENT

This agreement is between: The Board of Education of Mission Public School District #75

And _____________________________________________________________________________

Student’s Full Name (please print) And _____________________________________________________________________________

Father/Guardian Full Name (please print)

And _____________________________________________________________________________

Mother/Guardian Full Name (please print)

In consideration of The Board of School Trustees of Mission Public School District #75 agreeing to provide to the student an education program and a monitored Host Family program, the student and parents must read carefully and accept all of the terms and conditions set out in this agreement. By signing this agreement all parties hereby agree to be bound by and to honor its terms and conditions. Breach of this agreement may result in termination from the program.

STUDENT OBLIGATIONS I, , agree as follows:

Student’s First Name & Last Name

LAWS, RULES AND REGULATIONS

1. I agree to abide by the laws of Canada while a resident.

2. I will always respect cultural differences and understand that Canada is a multi-cultural country. I understand that discrimination based on nationality, gender, political or religious affiliation is illegal in Canada

3. I agree to reside with a homestay family selected through the Mission Public Schools International Student Host Family Program.

4. I agree not to purchase, use, or have in my possession, which includes my Host Family premises and school locker, any drugs not prescribed for me by a doctor. This includes all hallucinogenic substances, but does not include non-prescription remedies for minor illnesses such as colds.

5. I agree not to purchase, use, or have in my possession, which includes my Host Family premises and school locker, any alcoholic beverages.

6. I agree not to purchase, use, or have in my possession, which includes my Host Family premises and school locker, any weapons including firearms, air guns, knives, or martial arts implements.

7. I agree to respect the property of others and understand that any theft is a breach of the law.

8. I agree not to engage in fighting, bullying, racial taunting or similar activity.

9. I agree that I will not own, rent or drive a motor vehicle.

ATTENDANCE AND SCHOOL WORK 1. I agree to attend school on a regular basis and to bring a note from the Host Family parent(s) explaining any absence from school.

2. I agree to complete all homework and class assignments.

3. I agree to make a consistent and determined effort in my school work, to attempt to maintain passing grades, and to maintain good work habits in all subjects.

4. I agree to obey school rules as outlined in my school’s student handbook.

5. I understand that Plagiarism is academic dishonesty and is absolutely forbidden.

HOST FAMILY CONDUCT AND BEHAVIOUR OUTSIDE THE HOME AND SCHOOL 1. I understand and agree to follow the Host Family guidelines outlined in the Student Orientation Manual, and the house rules of my host family.

2. I agree not to move from my assigned Host Family and that any move to another Host Family is arranged through the Homestay Coordinator or a program staff member.

3. In the event of a problem or disagreement with my Host Family, I agree to notify the Homestay Coordinator or a program staff member promptly who will attempt to resolve any concern.

4. I will cooperate with my Host Family and respect their rules and guidelines.

5. If I want to travel outside the Mission District in Canada, I will complete the Travel Request form, with my Host Parents, a week before departure to ask permission from International Program Staff. I understand that cross border travel is allowed with prior approval and adequate medical insurance.

6. I agree not to visit such places as adult theatres, pornographic websites and lounges, bars or night clubs where alcoholic beverages are served.

Signature of Student Date

________________________________________________ __________________________________________________ Student e-mail address Student cell number (to be completed upon arrival)


ACTIVITIES WAIVER FOR INTERNATIONAL STUDENTS

CONSENT OF PARENT/GUARDIAN AND ACKNOWLEDGEMENT OF RISK

Dear Parent/Guardian of (Name of Student):

Please read carefully. If this form is not signed and returned by the first day of attendance in Mission Public School District 75, your child will not be

allowed to participate in the following activity(ies). By signing this form, you consent to your child’s participation in the following activities/destinations:

Camping

Caving/Spelunking

Go-Karting or Riding on All Terrain Vehicles (ATV’s)

Hiking

Horseback Riding

Mountain Biking

Rock Climbing

Sightseeing including land, water or air travel

Skateboarding

Snow Sports (Skiing, Snowboarding, Snowshoeing, Sledding, Tubing, and others)

Trampoline

Water Sports (including swimming, boating, kayaking, canoeing, sailing, surfing and others)

Whale Watching

Travel to the USA or other Canadian Provinces

Parent Please Initial to Approve Participation

DATE(S): During the academic program at Mission Public School District 75

PURPOSE OR EDUCATIONAL GOAL(S): Cultural activities and/or entertainment

METHOD OF TRANSPORTATION: Bus or Passenger Van or Host Parent vehicles

HEAD SUPERVISOR: Mission Public School District 75 approved supervisor

TOTAL NO. OF SUPERVISORS PLANNED: 1 adult to 14 students

COST TO THE STUDENT: Varies depending upon activity

POTENTIAL KNOWN RISKS

To participate in any activities, students must wear the appropriate safety clothing and equipment,

including but not limited to, a CSA Approved Helmet and /or Life Jacket for activities where this equipment is required.

THE BOARD WILL MAKE EVERY REASONABLE EFFORT TO ENSURE OR ASCERTAIN THAT:

a. The staff, volunteers and/or service providers involved are suitably trained and qualified.

b. The students are adequately supervised over all aspects of the program/activity.

c. The location(s) used are appropriate and safe for the activity(ies) and group.

d. Equipment used has been inspected and deemed appropriate and safe.

e. A Safety Plan is in place to identify and manage known potential risks.

f. An Emergency Plan is in place to deal with an injury or illness to any of the students. __ Parent Please Initial to Confirm Agreement

Risk Injury

Variable and unforeseen risks associated with

recreational activities listed above including

unforeseen circumstances, weather or water

conditions, horseplay, collisions with moving or

fixed objects, slips, falls, injury by an animal

including but not limited to kicks from a horse,

equipment failure or negligence on behalf of the

operator, student failure to heed safety

instructions, delayed rescue or accessibility, etc.

Head injuries, concussion, torn or damaged ligaments, broken bones, fractures, sprained joints, muscle injuries,

cuts, scrapes, bruises, burns, hypothermia, drowning, quadriplegia, frostbite, sunburns, damaged eye

sight, broken teeth, and/or other injuries including possible death

Travel to and from activity

Any injuries associated with a road vehicle accident including possible death


ACTIVITIES WAIVER FOR INTERNATIONAL STUDENTS CONSENT OF PARENT/GUARDIAN AND ACKNOWLEDGEMENT OF RISK CONT’D…

Parental Consent:

1. I/We accept the mode of transportation provided for the programs/activity(ies).

2. I/We acknowledge my/our rights and responsibilities to obtain as much information as I/we require about this program/activity(ies) and

associated risks and hazards, including information beyond that provided to me/us by the school or the Board.

3. I/We freely and voluntarily assume the risks/hazards inherent in the program/activity(ies) and understand and acknowledge that my/our

child may suffer personal and potentially serious injury arising from his/her participation.

4. My/Our child has been informed that he/she is to abide by the rules and regulations, including directions and instructions from the school’s

and/or service provider’s administrators, instructors, and supervisors over all phases of the program/activity(ies).

5. In the event my/our child fails to abide by these rules and regulations, disciplinary action may require his/her exclusion from further

participation.

6. I/We acknowledge that it is my/our duty to advise the International Student Program Staff of any medical and/or health concerns of my/our

child that may affect his/her participation.

7. I/We acknowledge that the Board may choose to cancel trips if travel conditions are deemed unsafe (e.g., weather, health advisory,

security). I/we accept that the Board may not be liable for any costs associated with such a cancellation.

8. I/We acknowledge that the trip supervisors may secure transport to emergency medical services as they deem necessary for my/our

child's immediate health and safety, and that I/We shall be financially responsible for such services.

9. Based on my/our understanding, acknowledgement, and consents as described herein, my/our child has my/our permission to participate

in the program/activity(ies) provided.

Name of Student

Name of Parent/Legal Guardian 1 Name of Parent/Legal Guardian 2

Signature of Parent/Legal Guardian 1 Signature of Parent/Legal Guardian 2

Date Date

Personal information contained on this form is collected under the authority of the British Columbia, Ministry of Education’s School Act,

for the purpose of participating in school trips. If you have any questions about this form, please contact the Program Manager.


AUTHORIZATION, VERIFICATION AND SIGNATURES A. I/We acknowledge that the Mission Public School District shall not be held liable for losses or expenses that may result from the Board being

unable to provide tuition/education owing due to labor disputes or other causes beyond its control.

B. I/We further acknowledge that the Mission Public School District also reserves the right to place students in a school program that best suits the student’s need for English language instruction and their academic goals.

C. I/We acknowledge that if my/our child’s personal, educational or homestay needs are greater than those disclosed in the application process, the

Mission Public School District has the right to charge for extra support if available, or to send the student home at the parent’s expense. D. I/We are aware that any inaccuracy in this application or the deliberate withholding of essential information will be grounds to permit the District at

its option, to terminate this agreement and send the student home at the parent’s expense. E. The agreement between the school district and the parents of a student in the program will be interpreted in accordance with the laws in the

province of BC and any litigation involving interpretation of the agreement will be conducted in BC, Canada. F. I/we understand and acknowledge that the Mission Public School District refund policy is as follows:

(a) Full Refund (less application fees) if the Canadian Immigration does not authorize the student to attend school in Canada. All requests must include the formal letter of refusal from Canadian Immigration and the original letter of acceptance issued by the International Student Program;

(b) Students who withdraw prior to their start date will receive two thirds (2/3) of their tuition fee and 100% of any prepaid homestay monthly fees;

(c) Students who withdraw within 30 days of the start of their program will receive one half (1/2) of their tuition fee;

(d) Students who withdraw after 30 days of the start of their program will not receive a refund on their tuition paid;

(e) Students who are asked to withdraw due to a violation of school or program rules will not receive a refund and student will be sent home at the parents’ expense.

G. Medical Release Authorization: I hereby accept that a School District #75 Mission Administrator may authorize necessary medical treatment, by a licensed physician, for my son or daughter without personal liability, in case of medical emergency. This authorization shall be valid for the full duration of the student’s enrollment in the Mission International Program.

By signing this Application, we hereby attest to the accuracy of the information provided and accept responsibility for all agreements, waivers and releases herein.

Name of Student

Name of Parent / Legal Guardian 1 Name of Parent / Legal Guardian 2

Signature of Parent / Legal Guardian 1 Signature of Parent / Legal Guardian 2

Date Date

_____________________________________________________________________________________________

The Board of Education of School District No. 75 (Mission) 33046 Fourth Avenue, Mission, BC V2V 1S5

Phone 604.826.6286 International Fax 604.820-2335


GRADE 9: FREE SCHOOL IMMUNIZATION Program – PARENT/GUARDIAN AUTHORIZATION

To protect your children, free school immunization programs are available to all students in British Columbia entering Grade 9. Grade 9 students are eligible to receive the Tetanus-Diphtheria-Pertussis booster if the last tetanus-diphtheria containing vaccine was 2 or more years ago. TETANUS-DIPTHERIA-PERTUSSIS BOOSTER: Tetanus (lockjaw) is caused by bacteria that live in the dirt. If you have a cut that gets infected with the tetanus bacteria, the bacteria can make a poison that can cause muscle paralysis. It is particularly serious if the breathing muscles are affected. Diphtheria is a serious infection of the nose and throat that kills 1 out of 10 people who get the disease. It can cause heart failure, paralysis, and breathing problems. Pertussis (whooping cough) is a very contagious disease of the lungs and throat. It can cause severe coughing spells that often end with a whoop, spitting up mucous or vomiting. The cough can last up to a month or two and happens more at night. Pertussis can also cause pneumonia, convulsions, brain damage or death. Possible vaccine reactions: Pain, swelling or redness at the injection site. These are usually mild and may last for 1 or 2 days. The reaction is more likely to occur if the person has received the vaccine more often than recommended. A small painless lump may also develop at the injection site, and usually disappears within 2 months. I, __________________________, request my child, _________________________, be immunized against Tetanus, Diphtheria, and Pertussis

(one [1] dose).

Grade 6 and 9 students are eligible to receive the HPV vaccine The HPV vaccine is provided free to girls in B.C. in grade 6 and 9 because:

Girls are best protected when they get the HPV vaccine before they become sexually active.

The vaccine prevents HPV infection but does not get rid of it once the infection occurs.

In teenage girls, the lining of the reproductive tract is still developing. This makes it easier for them to get infected with HPV. Benefits of HPV Vaccine In those who have never been infected with HPV, the Gardasil™ vaccine prevents:

7 out of 10 cases of cancer of the cervix.

9 out of 10 cases of genital warts. The vaccine is safe, very effective and has few side effects. Common reactions may include soreness, redness and swelling in the arm where the shot was given, headache and fever. I, __________________________, request my child, _________________________, be immunized against the HPV Virus. ** For any vaccine, there is an extremely rare possibility of a life-threatening reaction called anaphylaxis. This may include hives, difficulty breathing, or swelling of the throat, tongue, lips or eyes. If this happens, call 9-1-1 or your local emergency number. This reaction can be treated, and occurs in less than one in a million people who get the vaccine. It is important to stay in the clinic setting for 15 minutes after getting any vaccine. Report serious or unexpected reactions to your health care provider. If your child has had a shock-like, allergic reaction (anaphylaxis) to a previous dose of a vaccine or to any component of a vaccine, or if you have questions, call your local health unit or doctor before consenting for your child to receive the vaccine.**

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