Placement Change Form

FOREIGN EXCHANGE PROGRAM

Foreign Exchange Student Placement Change

Student's Name

First NameMiddle NameLast NameSuffix

Foreign Exchange Organization

Current Local Representative

What information is being changed about this student? (Mark all that apply)

What is the effective date of this change?

MonthDayYear

NOTE: District policies require local representatives to notify the Foreign Exchange Office within 24 hours of the change.

NEW LOCAL REPRESENTATIVE

New Representative's Name

New Representative's E-mail Address

HOST FAMILY INFORMATION

Change Type

Estimated date when a permanent family will be found.

MonthDayYear

How many times has this student been placed in a different family this year? (Including arrival families, temporary or emergency placements, etc.)

HOST PARENT #1

BECAUSE THIS STUDENT HAS HAD MORE THAN TWO PLACEMENT CHANGES DURING THIS YEAR, THE LOCAL REPRESENTATIVE'S REGIONAL/AREA SUPERVISOR MUST CONTACT THE FOREIGN EXCHANGE OFFICE FOR APPROVAL BEFORE THIS CHANGE WILL BE ACCEPTED. FAILURE TO FOLLOW THIS POLICY WILL RESULT IN THE ORGANIZATION BEING PLACED ON PROBATIONARY STATUS FOR THE NEXT SCHOOL YEAR.

First Name

Last Name

Phone Number #1

Area CodePhone Number

Phone Type

Phone Number #2

Area CodePhone Number

Phone Type

Host Parent E-Mail Address

HOST PARENT #2

First Name

Last Name

Phone Number #1

Area CodePhone Number

Phone Type

Phone Number #2

Area CodePhone Number

Phone Type

Host Parent E-Mail Address

Physical Address

City

ZIP Code

Does this family have a separate mailing address?

Mailing Address

City

ZIP Code

In order to speed up the process with updating host parent information at the school level, we are asking organizations to upload copies of the new host parents' proof of identity and proof of address when a student moves to a new home. Please see the guidelines below for these items:

* PROOF OF IDENTITY: Photocopy/photograph of host parent's driver's license, passport, military ID, or other official ID with picture.

* PROOF OF ADDRESS: Photocopy/photograph of one of the following--Recent utility bill, rent receipt, residence lease, home sales contract.

Please attached the required documentation here. This change will not be approved until this documentation has been submitted.

Attach Host Parent Identity/Residency Documents

Is this student being placed in the home of a single host parent?

Date of natural parent notification

MonthDayYear

Method of notification

Is this student being placed in a home with another foreign exchange student?

What is the other student's name?

Other student's home language

Other student's home country

Please attach documentation that both students and their natural parents have agreed to this double placement. This change will not be approved until this documentation has been submitted.

Attach Double Placement Documents

New School

Date of withdrawal from current school.

MonthDayYear

PLACEMENT CANCELLATION OR PROGRAM WITHDRAWAL

Date student will be withdrawn from CCSD.

MonthDayYear

Withdrawal reason

Other

PROGRAM EXTENSION

Student is extending the foreign exchange program and will now be going home at the end of the following semester

Please upload any documents that your organization needs the Foreign Exchange office to sign in relation to this change.

Attach File(s)

Please explain, in as much detail as possible, the reason for this change.

A confirmation receipt of this change form will be sent to the e-mail address you provide here:

Confirmation Email