Limestone District School Board

Application Form

Student's Information

First name *
Middle name
Last name *
English name (if you have one)
Date of Birth *
Gender *	Male Female
Citizenship *
First language *
Second language
Address 1 *
Address 2
City *
Province/State *
Country *
Postal code *
Telephone *
Fax
Email address *

Academic

When do you speak English? (Please check all that apply)	At school With friends At home
How do you rate your vocabulary level of English? *	Extensive Can carry on a conversation Basic words None
How do you rate your written level of English? *	Can write extensive essays Can write a letter, email, or memo Can not write
How many years have you studied English? *
Current grade *
When do you want to start school? *	1st semester (September) 2nd semester (February)
How long do you plan to stay? *	1 semester 2 semesters Longer
What is your goal? *	Graduate from secondary school in Canada Attend university / college in Canada Develop English skill only Other (please indicate below
Other goal

Health

Allergies
Medications
Other pertinent health information

Homestay

Do you require homestay? *

Yes
No

If no, please provide your address in Kingston and custodian's information

First name
Last name
Address 1
Address 2
City
Postal code
Telephone
Fax
Email address

Parents' Information

Father's Information

First name
Last name
Business telephone
Cellular telephone
Email address

Mother's Information

First name
Last name
Business telephone
Cellular telephone
Email address

Agent's Information (if applicable)

First name
Last name
Relationship/Agency name
Address 1
Address 2
City
Province/State
Country
Postal code
Telephone
Fax
Email address

Local Contact Person (if applicable)

First name
Last name
Relationship
Address 1
Address 2
City
Province/State
Country
Postal code
Telephone
Fax
Email address

A successful experience in the International Education Program of the Limestone District School Board depends upon regular class attendance, completion of all homework and assignments, and participation in all activities offered by the program.

I acknowledge that the International Education Program of the Limestone District School Board reserves the right to dismiss the students and return them home, at their own expense, without tuition refund for violating any of the rules set out by the program which are:

violation of school rules (frequent absences, fighting, misbehavior, academic dishonesty and/or lack of achievement in academic studies)
driving without a driver's license
use of alcohol or illegal drugs
holding a paying job
breach of homestay rules and expectations
engaging in any illegal activities
any other behavior or conduct that may be deemed inappropriate by Limestone District School Board and its staff

I therefore, agree to uphold the rules and regulations, and cooperate with administrators, teachers and the students in the Limestone District School Board.

I have read and understand the Refund Policy and I acknowledge that the International Education Program of the Limestone District School Board reserves the right to dismiss students and return them home, at the parents' expense, without tuition refund for violating any of the program rules or the laws of Canada.