SBRSD International Program Application
Name of International Agency *
Required
Personal Information
Family Name *
Your answer
Given 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 *
Your answer
If you have attended school in the United States previously, under which visa did you come? *
Home Address (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 Email Address *
Your answer
Mother's Name *
Your answer
Mother's Occupation
Your answer
Mother's Employer
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, 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? *
Where do you live during the school year? *
How many years of re-university study exist in your country's school system? *
Required
How many years will you have completed before coming to the United States? *
Estimate your English language skills *
Excellent
Good
Limited
Poor
Speaking
Reading
Writing
What proficiency test did you take? *
Your answer
What was you score? *
Your answer
Special Interests and Activities
What musical instrument do you play? (If any)
Your answer
Do you enjoy singing?
Name the sports in which you currently participate. How many years have you participated in each?
Your answer
Describe any other interests, hobbies, or other activities in which you are involved.
Your answer
What are your career plans?
Your answer
Have you ever traveled to the U.S. on an F1 or J1 visa? *
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?
If you answered yes to the above questions, please describe your limitations here.
Your answer
Do you have any allergies? *
Your answer
If yes, please list below the allergy and any treatment used, including medications.
Your answer
Are you able to live in a home with pets that live inside? *
If no, please list the animal(s) and reason(s) why.
Your answer
Smoking in prohibited for students. Can you live where other people smoke? *
What religion do you practice (if any)? *
Your answer
What religious services are you interested in attending in the U.S.?
Do you have any dietary restrictions? *
Your answer
Check any food you will not eat: *
Statement of Agreement
We understand and accept that Southern Berkshire Regional School District, in making 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 SBRSD's ability. We also understand that SBRSD will try to house all students approved, but can only accept as many students as can be accommodated. Furthermore, we understand SBRSD will try to accommodate our preferences regarding host family placement, however we understand that SBRSD cannot guaranty preferences. We understand that SBRSD families may be of any race, religion, structure, etc. and that we must accept the host family that SBRSD selects. I consent to SBRSD 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 SBRSD. We do acknowledge that the information we have provided in the admission packet to the complete and accurate. With the signatures below the student agrees to follow SBRSD'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 Southern Berkshire Regional School District.

Student Signature *
Your answer
Parent Signature *
Your answer
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