AEI Application – Required Information
Section 1: STUDENT INFORMATION
1. Full Name : Nguyen Thac Kieu Trinh
2. DOB: 13/06/2004
3. Gender: Female
4. Country: Vietnam
5. Citizenship: Vietnamese
6. Student Email: kieutrinh1306@gmail.com
7. Student Photo
8. Do You Have a US Visa : yes - if yes, Expiry Date of US Visa: 15/09/2017
Section 2& 3: 2 Parents Information
You may submit parent information for either one or two parents. Parent One is
the parent for which we will contact if necessary. Please note you will need to enter a
birthdate and an email address for all parents.
Father Mother
9. Relationship to Student X
10. Parent Last Name: Nguyen
11. Parent First Name: Thi Kieu Nga
12. DOB: 08/07/1977
13. Email: ngavietfurniture@gmail.com
14. Home Phone: +84 1203796456
15. Address: H7 Ecoxuan, Lai Thieu Ward, Thuan An Town, Binh Duong Province, Vietnam.
16. Who is the primary parent for correspondence – Mother.
Section 4: Emergency Contact Information (other than your parents)
17. Last name: Nguyen
18. First Name: Van Trung
19. Email: diemtrung8081@gmail.com
20. Telephone: 0907979492
Section 5: Start Date and Grade
21. Intended Start Date: 15/08/2018
22. Current Grade: 9
23. Requested Grade:
24. Length of Program: 9 months
25. Years of English Study: 7 years
26. Live with Bilingual Family? while attending NBISP? OK, but only English would be the best.
27. Graduated from High School in your home country? No
28. Participate in sport activities?
Yes. I participated in badminton and swimming, but not now anymore.
Section 6: Medical Information
Important:
It is very important for Atlantic Education International and for the safety of your
child that this form be completed with detailed and accurate information. Failure
to do so, may result in the termination of the program, at any point, with no
refund. The health insurance for our students does not cover pre-existing
conditions, pregnancy and delivery, or visits to the dentists, except if it is an
accident.
If you wear braces, we suggest you remove them before traveling to New
Brunswick or budget this extra cost for regular visits to the dentist.
If you wear eye glasses, we suggest you bring an extra pair; eye doctor
appointments are not covered by the student's insurance plan.
29. Existing Allergies ? No
30. Do you require an Epipen? No
31. Ongoing Health Concerns? No
32. Learning Issues? No
33. Social or Behavioral Issues? No
Section 7: Homestay
NOTE: We will do our best to accommodate all of your requests. However, please note that
NBISP does not guarantee placement in choice of School desired. Placement will be done
according to student programming, ESL needs and availability of school space.
34. Require Homestay Placement: yes, if yes, please answer the following:
35. Describe personality: A typical lazy person, but feeling enthusiastic to try new things.
Happy, sometimes can be a little bit stupid or slow, but I hope to receive the
advices. I am trying to change to be a more active person so I am counting on the
new life, new experiences.
36. Family style preference: Small size, any kind of family’ habits
37. Pets: any pets, except for spiders.
38. Instruments: can play a little bit piano
39. Sports : Running, badminton, climbing, I want to try basketball one day.
40. Hobbies:
- At the moment, the puzzle is one of my savor for life.
- I adore the arts, especially paintings. Also, I like to read classic books during
my free time.
- I could be an introvert or an extrovert depending on my feelings.
- I like outdoor activities, but I do not play sports, except for swimming.
- I also like manga and animated stuff like other children. I used to addict
them, but not anymore.
- And I have a weird hobby: I like the darkness.
41. Dietary requirements: enough calories.
42. Are you willing to eat any food? I can eat anything, except for hotpot or anything too
spicy.
43. Are you willing to eat fish? Yes
44. Are you willing to eat poultry? Yes
45. Are you willing to eat pork? Yes
46. Are you willing to eat beef? Yes
47. Are you willing to eat dairy (milk products)? Yes
48. Does Student Smoke? no
49. Willing to live with other exchange students? Yes, except for Chinese one.
50. Willing to live with single parent? Yes
51. Willing to live with single parent family with children? Yes
Section 8 - Custodianship
You only need to answer this question if you require homestay placement from NBISP.
52. Require complimentary custodianship: Yes
Section 9: Documents
53. Record of grades (last 2 years)
54. Passport picture page
55. Immunization records:
56. Custodian Document (if not using NBISP):
57. Student’s Letter to Host family
58. Photo album PDF:
Section 10: Legal (need signature on 2 forms)
59. Participation Terms (attached)
60. Permission to Publish Photograph (attached)
