Fillable Homestay Family Application - Adult Student (Spokane Community College)

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Homestay Family Application - Adult Student (Spokane Community College)

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Page 1 of 3
CCS 5809 (Rev. 05/18)
Marketing and Public Relations
Global Education
HOMESTAY STUDENT APPLICATION
18 Years Old or Above
To apply, complete this form and return it with the nonrefundable placement fee to:
Spokane Falls Community College
International Programs MS 3011
3410 W Fort George Wright Dr
Spokane WA 99224-5288 USA
Spokane Community College
International Programs MS 2151
1810 N Greene St
Spokane WA 99217-5399 USA
Homestay Application fee of $200.00 will be charged on students’ CCS account.
Placement is not guaranteed and fee is nonrefundable, unless a homestay family is not available.
Student Last name
:
First name
:
Gender:
Female Male
Date of birth
:
Country
:
Homestay choices: $700.00 a month for Homestay with food OR $400.00 a month for Homestay without food
Estimated date of arrival
:
Student E-mai
l:
If Applicable, recruiting agent E-mail:
HOMESTAY STUDENT PROFILE
While all student preferences will be considered, CCS cannot guarantee they will all be satisfied.
Father’s and/or Mother’s name and occupatio
n:
Would you prefer small children in your host family who are under 6 years old?
Yes No No preference
Would you prefer older children in your homestay family who are between 6 and 21?
Yes No No preference
Have you traveled outside your country before?
Yes No
Explain:
Do you smoke?
Yes No
Explain:
Is it okay if there are smokers in your homestay family?
Yes No
What hobbies, sports or other activities do you enjoy?
Are you planning to drive a car as soon as you arrive?
Yes No
How much interaction and conversation with your homestay family do you prefer?
Every day Several times a week and on weekends I’m very independent – weekend conversation ok
I would like to live in a home that is more:
Quiet or Busy-active
Explain:
Are you a vegetarian, someone who eats no meat?
Yes No
Explain:
Do you have any allergies to food, drugs, animals or anything else?
Yes No
Explain:
Page 2 of 3
CCS 5809 (Rev. 05/18)
Marketing and Public Relations
Do you have any health conditions that would prevent you from participation in normal and regular physical activities?
Explai
n:
Disabilities: Students who plan to request accommodations due to a disability must submit a request through the CCS
Global Education Office at Internationalhomestay@ccs.spokane.edu. Such requests must be submitted at least 2
months prior to student’s first quarter of enrollment. More information regarding CCS Administrative Policy 3.20.01-A,
Accommodations for Students with Disabilities is available at http://www.ccs.spokane.edu/getdoc/80717e7b-4e04-4c51-
bfa6-0b48d2a64bf3/3-20-01A-Accommodations.aspx
Is there anything else you’d like us to know about you?
Please include a photo and short letter about yourself.
Student's Rights and Responsibilities Regarding Homestay Program
Students who participate in the Homestay Program are subject to specific rights and responsibilities.
Failure to comply may result in the student's removal from the Homestay Program.
The applicable rights and responsibilities are detailed in CCS Policies and CCS Rules and Regulations.
Student Rights and Responsibilities
Additionally, students must comply with the following requirements:
1. Respect & follow the guidelines of your homestay family
2. Pay for any damage you or your guests cause to homestay family home or property.
3. Pay all personal bills and obligations
4. Use prepaid phone card or personal cell phone; do not charge calls on homestay phone.
5. Abstain from illegal activities at all times during your stay
6. Try to resolve conflict with your homestay family by talking to with International Homestay Manager:
Ashley Ding.
7. Notify family and International Office prior to moving out, 30 days’ notice preferred.
8. Communicate to your homestay family if you’ll not be home for dinner or arriving late
9. Pay homestay fee on the 1
st
of each month – NO refunds if you leave without 30 days’ notice
10. Attend classes regularly.
Page 3 of 3
CCS 5809 (Rev. 05/18)
Marketing and Public Relations
Agreement, Release, Liability Waiver, and Assumption of Risk by Student
In the State of Washington, individuals who are who are 18 years old or above are generally considered an adult.
I
(name of student),
agree to the following terms and conditions which I understand will constitute a
legally binding Agreement, Release, Liability Waiver, and Assumption of Risk upon my signature.
I understand that a Homestay placement is a placement in a private family home and includes a private room, bathing facilities, and a
place to study. The Homestay family provides necessary household items such as linens and towels. The student's room is
furnished, including a bed/bedding, desk or table, lamp dresser, and closet. In the Homestay with Food Plan, the Homestay family
is responsible for providing food for meals and snacks seven days a week. I may also choose a Homestay without Food Plan, and
agree to purchase, prepare all my own food and clean up afterwards.
I understand that I’m obliged to follow the rules of the Homestay family. All members of the Homestay family will be proficient in
English and will only speak English when I/the student, am present. The primary form of transportation for I/the student is the city
bus; however, the Homestay family may occasionally offer me a ride in their personal vehicles.
I consent to my placement in a Homestay family. Additionally, I understand and agree that there may be modifications in my
Homestay placement. I the student, agree to release the STATE OF WASHINGTON, Community Colleges of Spokane (CCS), the
Homestay families, and their officers, agents, employees, agencies, and departments from any responsibility and liability for changing
who will be assigned as the Homestay family prior to or after my arrival in the United States, placement in more than one Homestay
family or denial of placement if an appropriate Homestay family is not available."
Medical
I, the student agree to purchase and maintain adequate medical insurance and personal liability insurance on my personal
belongings while I attend CCS. The medical insurance shall comply with any requirements mandated by the U.S. Visa Program. I
agree and understand that CCS assumes no responsibility for verifying the medical insurance standards of coverage if purchased
outside the CCS Lewer plan. I agree and understand that CCS assumes no responsibility to verify the purchase/adequacy of my
personal liability insurance.
I authorize the Homestay family to take whatever action they feel is reasonably warranted to obtain medical and dental attention for
myself during the period in which I live with the homestay family. This authority and permission includes, but is not limited to the
following: medical exams, testing, x-rays, anesthetic, surgical and hospital care and treatment, medical procedures, and treatment to
be performed for me by a licensed health care provider, or hospital when, in the sole discretion of the attending health care provider,
such care, treatment and procedures are immediately necessary or advisable in the interest of my health and well-being, and it’s not
advisable to take time to contact family members in advance. Under the circumstances set forth above, I elect to not be informed in
advance of the nature and character of the proposed treatment, its anticipated results, possible alternatives, and risks, complications
and anticipated benefits involved in the proposed treatment and the alternative forms of the treatment, including non-treatment.
I further grant permission for the health care treatment providers, the homestay family, and CCS to release information regarding me
to health care providers and facilities who are engaged in providing health care to me child under these circumstances.
I, the student agree to be financially responsible for the costs of all medical and dental care and treatment obtained or provided to me
during my attendance at CCS and stay with the Homestay family. I and my heirs, assigns, or other successors in interest agree to
release the STATE OF WASHINGTON, Community Colleges of Spokane (CCS), the Homestay families, and their officers, agents,
employees, agencies, and departments from any responsibility or liability for any medical or dental related costs.
Additional Costs:
I agree to reimburse my Homestay for repairs/costs incurred by me in the event of damage to the Homestay family home or property.
Activities, Travel and Trips:
I understand and acknowledge that there is a risk of injury to me by my participation in trips and activities with my Homestay family.
I further understand that it is voluntary for me to participate in trips and activities with the Homestay family and that CCS and the
Homestay program do not require my participation. I hereby release the Homestay Family, CCS and the State of Washington, their
employees, officers, agents, and trustees, and waive any and all right and claims for damages from any and all injures that I may
suffer as a result of my participation in trips and/or activities.
I agree to hold harmless and indemnify the Homestay Family, CCS and the State of Washington, their employees, officers, agents,
and trustees for any action, claim, or proceeding initiated as a result of any injury suffered by me or any third party through my
participation in any trips and/or activities. Typically these activities may include, but are not limited to: transport in Homestay family
member vehicles to shop, commute to/from school, dining out, community/religious events, family recreational, vacation activities etc.
Student’s signature:
Date:
Parent’s signature:
Date:
(If student is 17 years old)
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Homestay Family Application - Adult Student (Spokane Community College)

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Completed 8 October 2020

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