NCSD International Program Application
Name of International Agency
Personal Information
Family Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Country of Birth *
Your answer
Country of Citizenship *
Your answer
Gender:
Passport Number *
Your answer
Passport Expiration Date *
MM
/
DD
/
YYYY
If you have attended school in the United States previously, what visa did you come under? *
Required
Home Address *
Please include Zip and Country Codes
Your answer
Your Email Address *
Your answer
Home Telephone Number *
Include Area/City Code
Your answer
Mobile Phone Number
Your answer
Family Information
I live with: *
Please check all that apply.
Required
Father's Name (last, first, middle initial) *
Your answer
Father's Occupation
Your answer
Father's Employer
Your answer
Father's Business Phone
Your answer
Father's Email Address
Your answer
Mother's Name (last, first, middle initial) *
Your answer
Mother's Occupation
Your answer
Mother's Employer
Your answer
Mother's Business Phone
Your answer
Mother's Email Address
Your answer
List Brothers, Sisters, and Step Siblings *
(Separate with commas.)
Your answer
Emergency Information
If we are not able to contact your parents tell us who to contact.
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Email Address *
Your answer
Emergency Contact Relationship
i.e Aunt, Uncle, family friend, etc.
Your answer
Academics
Official transcripts translated to English must be sent as well.
Name of Current School *
Your answer
Address *
Your answer
Phone Number *
Your answer
Principal/Headmaster Name *
Your answer
What type of school do you currently attend? *
Public
Private
Where do you live during the school year? *
Check all that apply.
Required
How many years of pre-university study exist in your country's school system? *
11
12
13
14
How many years will you have completed before coming to America? *
9
10
11
12
13
Estimate your English language skills. *
Excellent
Good
Limited
Poor
Speaking
Reading
Writing
What proficiency test did you take? *
Your answer
What was your score? *
Your answer
Special Interests and Activities
What, if any, musical instrument(s) do you play and how long have you studied each? (list in order of your ability on each)
Your answer
Do you enjoy singing?
Yes
Not Really
What sports do you participate in now and how long have you participated in each?
Your answer
Describe any other interests, hobbies or other activities you are involved in.
Your answer
What are your career plans?
Your answer
Have you ever traveled to the US on an F1 or J1 visa? *
Yes
No
Placement Information
Do you have any health restrictions, physical handicaps, learning disabilities or limitations to participating in any activities that the school or host family should be aware of? *
Yes
No
If you answered yes to the above question, please describe your limitations here.
Your answer
Do you have any allergies? *
Yes
No
If yes, please list below the allergy and any treatment used including medication(s):
Your answer
Are you able to live in a home with pets that live inside? *
Yes
No
If no, please list the animal(s) and reason(s) why.
Your answer
Smoking is prohibited by students. Can you live where other people smoke? *
Yes
No
What religion do you practice, if any? *
Your answer
How often do you attend services?
Your answer
What religious services are you interested in attending in the US?
My own
My host family's, even if different from my own
My own and my host family's
I'm not interested in attending services
Do you have any dietary restrictions? *
(medical, religious, self imposed)
Yes
No
If yes, please explain.
Your answer
Remember you will be eating what your host family eats. Check any food you will not eat: *
Required
Statement of Agreement
We understand and accept that Newcomb Central School District (NCSD), in making its selections and placements, does not discriminate on the basis of race, color, national origin, sexual orientation, religion or gender. Individuals with disabilities will be accommodated to the best of NCSD's ability. We also understand that NCSD will try house all students approved, but can only accept as many students as can be accommodated. Furthermore, we understand NCSD will try to accommodate our preferences regarding host family placement; however we understand that NCSD cannot guaranty preferences. We understand that NCSD families may be of any race, religion, stucture, etc and that we must accept the host family that NCSD selects. I consent to NCSD using limited information including pictures from my son/daughter's application for promotional purposes. In addition, we authorize the release of medical and school information to NCSD. We do acknowledge that the information we have provided in the admission packet to be complete and accurate. With the signatures below the student agrees to follow NCSD's Code of Conduct and any serious breach of conduct may result in program cancellation or the early return of the applicant. ATHLETIC ELIGIBILITY OR PARTICIPATION IS NOT GUARANTEED.

By typing our names in the signature lines below, we attest that all information has been given to the best of our knowledge and we agree to all the terms and conditions of Newcomb Central School District.
Student Signature *
Your answer
Parent Signature *
Your answer
Submit
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