Foreign Exchange Student Placement Change Request

Foreign Exchange Student Placement Change Request
APPLICANT INFORMATION
Student's Full Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Zoned School*
Local Representative*
Foreign Exchange Organization*
What information is being changed?*

Local RepresetnativeNew Host FamilyHost family Contact InformationChange of School AssignmentExtension of ProgramDouble PlacementSingle PlacementWithdrawal from CCSSD
What is the effective date of this change?*

MonthDayYear
Date
Note: CCSD policies require local representatives to notify the Foreign Exchange Office within 24 hours of the changes. If a student has had two placement changes, please contact the Foreign Exchange Office for approval. Failure to adhere to this policy will result in the organization being placed on probation for the following year.
New Local Representative*
E-mail*
Phone Number*

Area CodePhone Number
Requested School
Is this student being placed in the home of a single host parent?*

YesNo
Date of natural parent notification of single host parent placement

MonthDayYear
Method of notification

Phonee-mailFaxLetterSigned Form
Host Placement Type*

Permanent Host FamilyArrival Family
Estimated date when the student will be permanently placed.*

MonthDayYear
Date
How many times has this student been placed with a different family this year? (including arrival families, temporary or emergency placements, etc.)*

123 or more
Host Parent #1*

First NameLast NameSuffix
Phone #1*

Area CodePhone Number
E-mail*
example@example.com
Host Parent #2

First NameLast NameSuffix
Phone #1

Area CodePhone Number
E-mail
Host Parent Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Host Family Mailing Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this student being placed in a home with another foreign exchange student?*

YesNo
Other student's name
Other student's home country
Other student's home language
Be sure to attach documentation showing that both students and their natural parents have agreed to this double placement. This application will not be approved until this documentation has been submitted.
The following documentation should be attached to this application. Do not submit an application unless you have attached all of the required documentation. You can upload all documents as one single file.
Please attach documentation here*

Upload a File

Cancelof
A confirmation receipt of this application will be sent to the e-mail address you provide here:*

Confirmation Email
E-mail
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