N O N - FA I R M O N T H O M E S TAY F O R M

INSTRUCTIONS 1. The Non-Fairmont Homestay Form must be completed in English and all supporting documents must be supplied in English. 2. The Non-Fairmont Homestay documentation must be filled in by hand, scanned and sent by email to Fairmont Private Schools – send to Mrs. Amy Childs [email protected] 3. The following documents are required arrival documents 4. Non-Fairmont Homestay Terms and Conditions 5. Guardian Agreement: International Students 6. Homestay Waiver of Liability, General Release, Assumption of Risk and Indemnity Agreement

Fairmont Private Schools | Non-Fairmont Homestay Form

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Non-Fairmont Homestay Terms and Conditions Academic Year 2017-2018 Student First Name:

Student Last Name:

Student ID:

The following terms and conditions outline the policies that permit International Students not living with a parent to reside in housing outside of the Fairmont Homestay program while attending Fairmont Private Schools (FPS). It is the responsibility of the student, Guardian or Parent appointed host family to familiarize themselves with and to adhere to these terms and conditions. Failure to adhere to any of the following terms and conditions may result in disciplinary action, including but not limited to, removal from Non-Fairmont Homestay residence and placement into Fairmont Homestay, suspension from FPS, and/or cancellation of the I-20 Visa.

TERMS AND CONDITIONS: 1.

The Student must report to the Dean of Students Office, accompanied by a Parent, Guardian, or Parent-appointed Host Parent, with whom they will be residing, no later than the first day of school. The student must present a signed Guardian Agreement.

2.

The Parent, Guardian or Parent appointed Host Parent must sign the Non-Fairmont Homestay Terms and Conditions form.

3.

The Student must bring a Waiver of Liability, General Release, Assumption of Risk and Indemnity Agreement signed by the Student’s Parent or Legal Guardian.

4.

While attending FPS, the Student must be living with parent(s) or a legal relative. In the absence of a parent or legal relative, the parent may appoint an individual to serve as the Host Parent while the student is attending FPS. All designated relatives or Host Parents must be 25 years or older and live full time in the residence with the Student.

5.

Students are expected to live in a safe, healthy and clean environment. The living environment of the Student must be conducive to education and learning. FPS reserves the right to mandate a student to reside in a Fairmont Homestay if the Student is absent for 10 or more days and/or maintains a GPA under 2.0.

6.

Students and Parent, Guardian and/or Host Parent must notify the Dean of Students Office within 48 prior to any change in residence. A new Guardian Agreement must be signed and verified prior to the residency verification check. A designated school official will perform a residency verification check within 7 days. During this visit, proof of identification is required, along with proof of residence (e.g., utility bill, lease agreement, homeowner’s insurance policy).

7.

FPS reserves the right to cancel a Student’s I-20 Visa if the Student violates the Non-Fairmont Homestay Terms and Conditions. All costs associated with the cancelation of the I-20 Visa and return home are the responsibility of the Parent.

8.

Unapproved absences are subject to the FPS Attendance Policy. Failure to timely notify FPS of a student’s absence as required will subject the Student to disciplinary action as set forth in the Student Handbook. In addition to the Attendance Policy stated in the Student Handbook, International Students are required to adhere to the following:

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Fairmont Private Schools | Non-Fairmont Homestay Form

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• • •

1st Offense: A written notification will be sent to the Host Family and the Student will be required to meet with the Dean of Students. 2nd Offense: A written notification will be sent to the Parent/legal guardian. The Dean of Students will meet with Host Family and Student. Final Offense: Student will be given 7 days to transfer into the Fairmont Homestay Program. Failure to timely transfer into our Homestay Program may result in the cancellation of the I-20 Visa. All costs associated with the cancelation of the I-20 Visa and return home are the responsibility of the Parent.

9.

If a Student is absent, the Parent, Guardian or Host Parent must contact the attendance office by 9:00 am on the day of the absence. The student must bring a signed letter from the Parent, Guardian or Host Parent explaining the reason for the absence the following day. E-mail will NOT be accepted.

10.

False information given to FPS may result in the immediate removal of the Student from the Non-Fairmont Homestay residence and may result in the cancellation of the Student’s I-20 Visa. If a student is expelled all costs associated with the cancellation of the I-20 Visa and the students return trip to their home country will be the responsibility of the Parent.

I have read and understand the terms and conditions. I understand that failure to adhere to any of these terms and conditions may result in disciplinary action, including but not limited to, removal from Non-Fairmont Homestay residence, suspension or expulsion from FPA, and/or cancellation of the Student’s I-20 Visa.

ACCEPTED AND AGREED: Print Student Name: ____________________________________________________________________________________________________ Student Signature: _________________________________________________________________________ Date: _______/_______/_______ Print Parent/Host Name: _________________________________________________________________________________________________ Parent/Host Signature: _____________________________________________________________________ Date: _______/_______/_______

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Fairmont Private Schools | Non-Fairmont Homestay Form

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Guardian Agreement: International Guardian Agreement: Internationa Guardian Students Agreement: International Students Students Academic Year 2017-2018 Academic Year 2017-2018 Academic Year 2017-2018Student Last Name: Student First Name: Student Last Name: Student First Name: Student ID: Student First Name:

Student Last Name:

Student ID:

INSTRUCTIONS:

INSTRUCTIONS:

1. The parent of the international student shall select an adult g The parent of the international student shall select an adult guardian, who is at least 25 years of age, who lives within a reasonable distance of the school where the student will at a reasonable distance of the school where the student will attend and who will agree to the Guardian Responsibilities Agreement. 1. The parentinofthis theAgreement. international student shall select an adult guardian, whodescribed is at least in 25this years of age, who lives within described 2. The parent is to fill in his/herResponsibilities portion of the Guardian Agreem reasonable distance of the school studentAgreement will attend and return who will agree to the Guardian 2. a The parent is to fill in his/her portionwhere of thethe Guardian it to the Guardian for completion. 3. The Guardian shall complete the remainder of the Agreemen in this Agreement. 3. described The Guardian shall complete the remainder of the Agreement and return it to Fairmont Private Schools(FPS), The Dean of Students Office. 2. The parent is to fill in his/her portion of the Guardian Agreement and return it to the Guardian for completion. Students Office. 4. itThe Agreement must Schools(FPS), be fully completed and of returned to FPS 3. the remainder the Agreement and return to Fairmont Private The Dean 4. The Guardian Agreementshall mustcomplete be fully completed and of returned to FPS before the student may attend school. Students Office. GUARDIAN 4. The Agreement must be fully completed and returned to FPS before the studentRESPONSIBILITIES may attend school. GUARDIAN RESPONSIBILITIES 1.

INSTRUCTIONS:

As the Guardian of __________________________________________ (stu As the Guardian of __________________________________________ (student’s name) I agree to the following while the student is GUARDIAN RESPONSIBILITIES attending Fairmont: attending Fairmont: As the Guardian of __________________________________________ (student’s name) agree toresponsibility the followingfor while the student is the school year 1. II assume the student during 1. I assume responsibility for the student during the school year and regularly scheduled vacations from school. This attending Fairmont: will include Thanksgiving, Winter Break, Spring Break, and a will include Thanksgiving, Winter Break, Spring Break, and any other breaks that may occur during the School Year. My responsibility includes, is notThis limited to, providing tran 1. IMy assume responsibility for the student during the school year and regularly scheduled vacations from but school. responsibility includes, but is not limited to, providing transportation to and from school, or making appropriate arrangements with the Fairmont transportation department t will include Thanksgiving, Winter Break, Spring Break, and any other breaks that may occur during the School Year. arrangements with the Fairmont transportation department to and from school, and providing supervision during school breaks. My responsibility includes, but is not limited to, providing transportation to and from school, or making appropriate breaks. 2. school, I assume for ensuring thatschool the student resides i with the for Fairmont transportation department andhome from and responsibility providing supervision during 2. arrangements I assume responsibility ensuring that the student resides to in my at all times or in a Fairmont approved Homestay home. breaks. home. 3. at Iall assume responsibility for approved reporting travel plans regarding a 2. theplans student residesarrival in my home times orininadvance a Fairmont Homestay 3. I assume responsibility for ensuring reporting that travel regarding and departure well to FPS. 4. I assume responsibility to keep in direct contact with the Inte 4. home. I assume responsibility to keep in direct contact with the International Student Manager at FPS regarding conflicts, problems orinother issues that may need to be addressed. I fu 3. Iproblems assume responsibility for reporting travel plans regarding arrival and departure well advance to FPS. or other issues that may need to be addressed. I further assume responsibility for the above student if he or she is disciplined suspension or expulsion from school). I w 4. Iisassume responsibility to keeporinexpulsion direct contact the International Manager (i.e., at with FPS regarding disciplined (i.e., suspension from with school). I will also beStudent the decision-maker respect to conflicts, the student’s academic and for social life while he or ifshe problems or other issues that may need to be addressed. I further assume responsibility the above student heisorwithin she my care an academic and social life while he or she is within my care and custody. 5. I will provide FPS with a copy of an official document that ver disciplined suspension oran expulsion from school). will also beage theand decision-maker 5. is I will provide (i.e., FPS with a copy of official document that Iverifies my residence. with respect to the student’s 6. I agree, should the student choose to move out of my home, and social life while he ortoshe is within andtocustody. 6. academic I agree, should the student choose move out ofmy mycare home, notify the International Student Manager. as soon as possible, but no more than 48 hours within the student depa 5. Ipossible, will provide FPSmore with than a copy an official that verifies my age and residence. but no 48ofhours withindocument the student departure. 6. I agree, should the student choose to move out of my home, to notify the International Student Manager. as soon as Print Guardian Name possible, but no more than 48 hours within the student departure. Relationship Print Guardian Name to Student Print Guardian Name Guardian Signature

Relationship to Student Guardian Signature

Guardian Signature Fluent in English:

Yes

No

Other (indicate):

Fluent in English: Street Address

Yes

No

Other (indicate):

Fluent in English:

State

Zip Code

City Home Phone

State

Zip Code Country Home Phone Cell Phone

City

Country

Home Phone Work Phone

Cell Phone Work Phone Email

Work Phone

Email

Other (indicate):

Zip Cod

State

Ce

Em

PLEASE SEE BA

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No

Street Address

Street Address City

4836-4291-3038.1

Yes

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Fairmont Private Schools | Non-Fairmont FormPM 4 REV Homestay 02/06/17 2:39

FPS will only discuss the student’s education, discipline and other pertinent details with the biological parent and/or parentappointed guardian As the parent of the above-named student, I hereby authorize __________________________________________ (name of Guardian) to take care of and assume responsibility for my child as I would do if personally present. In the event the above-mentioned guardian is unable to fulfill his/her duties, I will immediately secure the services of another individual to serve as guardian. I assume responsibility to Fairmont Private Schools for any financial obligations, including medical care, reasonably and necessarily incurred on behalf of the above student while he/she is a student at Fairmont.

AUTHORIZATION TO TREAT MINOR I the undersigned parent(s) or legal guardian of __________________________________________ (Full printed name of minor), a minor, do hereby authorize, consent to, and give permission to medical personnel selected by the adult leader in charge, to hospitalize, secure anesthesia, x-ray examination, dental, medical or surgical treatment for such minor, and agree to pay for such services. This authorization is given pursuant to California Family Code §6910, and is intended to constitute such authorization as may be necessary or required in any jurisdiction with in which this Authorization may be presented. Print Parent/Guardian Name: ____________________________________________________________________________________________ Signature of Parent/Guardian: ______________________________________________________________ Date: _______/_______/_______ Relationship: ___________________________________________________________________________________________________________

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Fairmont Private Schools | Non-Fairmont FormPM 5 REV Homestay 02/06/17 2:39

Homestay Waiver of Liability, General Release, Assumption of Risk and Indemnity Agreement Academic Year 2017-2018 Student First Name:

Student Last Name:

Student ID:

WAIVER: In consideration of ______________________________________ (“Student”) being permitted to reside outside of the Fairmont Homestay program in a Non-Fairmont Homestay residence, I, for myself, and on behalf of Student, my heirs, personal representative or assigns, do hereby covenant not to sue and forever generally release, waive, and discharge, Fairmont Private Schools (FPS), its officers, employees, agents, divisions, affiliates, attorneys, successors, assigns, and insurers (collectively “Released Parties”) from any and all liability, claims, demands, actions, causes of action, known or unknown, suspected or unsuspected, including but not limited to the negligence of the Non-Fairmont Homestay family or anyone associated therewith, FPS, or any of the Released Parties resulting in personal injury, accident, illnesses and/or death and/or property loss, occurring during and/or arising from but not limited to Student’s voluntary decision to live in the Non-Fairmont Homestay residence. Signature of Participant: ____________________________________________________________________ Date: _______/_______/_______ Signature of Parents/Guardians of Minor: ____________________________________________________ Date: _______/_______/_______ Signature of Parents/Guardians of Minor: ____________________________________________________ Date: _______/_______/_______

ASSUMPTION OF RISKS: Participation in Non-Fairmont Homestay carries with it certain inherent risks that cannot be eliminated regardless of the care taken by FPS, its related entities, and the Released Parties to avoid injuries. We have read the previous paragraphs and we know, understand, and appreciate these and other risks that are inherent in NonFairmont Homestay. We hereby assert that Student’s living in the Non-Fairmont Homestay residence is voluntary and that we knowingly assume all such risks. We expressly understand and agree that FPS is not responsible for the safety and the well-being of Student during time he or she lives in the Non-Fairmont Homestay residence.

INDEMNIFICATION AND HOLD HARMLESS: We also agree to indemnify and hold FPS and the Released Parties harmless from any and all claims, actions, suits, procedures, costs, expense, damages and liabilities, including attorney’s fees and costs brought as a result of Student’s voluntary decision to live in the Non-Fairmont Homestay residence and to reimburse FPS and the Released Parties for any such expenses incurred.

INSURANCE AND MEDICAL CARE: We shall ensure that Student is fully insured with medical insurance during the time he or she lives in the Non-Fairmont Homestay residence. Should it be necessary for Student to obtain medical care while living in the Non-Fairmont Homestay residence, we hereby give the legal or parent-appointed guardian permission to use his or her judgment in obtaining medical care for Student, and give permission to the physician selected by the legal or parent-appointed guardian to render medical care deemed necessary and appropriate by the physician. We understand that FPA has no insurance covering such medical or hospital costs incurred by Student and, therefore, any cost incurred for such treatment shall be our sole responsibility.

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APPLICATION OF FPS RULES OF CONDUCT: We acknowledge that all of FPS’ rules of conduct shall apply during the duration of Student’s stay in the Non-Fairmont Homestay residence. We acknowledge that participants shall be bound by California and United States laws during the period of Student’s stay in the Non-Fairmont Homestay residence and that there shall be no alcohol, illegal drug use or possession of alcohol or illegal drugs by Student at any time. We acknowledge that FPS shall not be responsible if Student breaks the law or breaks the rules of conduct of FPS and that we shall bear any expenses related thereto, including those associated with the cancelation of Student’s I-20 Visa and return home. We acknowledge that the Non-Fairmont Homestay terms and conditions apply and if FPS finds Student breaking the law, breaking the rules of conduct, and/or engaging in inappropriate behavior, FPS may impose disciplinary action, including but not limited to, removal from Non-Fairmont Homestay residence, suspension from FPS and/or cancellation of the I-20 Visa. We shall take full responsibility and pay all expenses should Student be sent home for such violations. There shall not be any refund of fees related to the Homestay program if Student is disciplined, removed from Non-Fairmont Homestay resident, suspended, or Student’s I-20 Visa is cancelled.

SEVERABILITY: The undersigned expressly agrees that the foregoing Waiver of Liability, General Release, Assumption of Risk, Application of Law/ Rules, and Indemnity Agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, illegal or unenforceable, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

ACKNOWLEDGMENT OF UNDERSTANDING: We have read this Agreement, fully understand its terms, and understand that we are giving up substantial rights, including our right to sue. We acknowledge that we are signing the Agreement freely and voluntarily, and intend by our signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Signature of Participant: ____________________________________________________________________ Date: _______/_______/_______ Participant’s Age (if minor): _____________________________________________________________________________________________ Signature of Parents/Guardians of Minor: ____________________________________________________ Date: _______/_______/_______ Signature of Parents/Guardians of Minor: ____________________________________________________ Date: _______/_______/_______

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Fairmont Private Schools | Non-Fairmont Homestay Form

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