International Student Application

Medical Release and Consent to Treat

Jenison Public Schools recognizes its responsibility to provide medical services to its students, especially in
time of emergency. In order to adequately care for students, the following consent is required.

Student’s Last Name First Name Middle Initial

We (I) consent for Jenison Public Schools’ staff and/or the host parents, without liability or expense to
themselves, to dispense over-the-counter medication and/or administer such medical treatment as may be
necessary or advisable in case of illness or accident.

In the event that a physician determines that immediate medical treatment or surgery is necessary for the student
and one or both parents or the legal guardian cannot be immediately contacted, authorities of Jenison Public
Schools are hereby authorized to approve such treatment as may be determined by the physician at that time.

We (I) accept full responsibility for the cost of any medical care or emergency treatment, which may become
necessary. In authorizing Jenison Public Schools as our (my) agent, we (I) understand that the school shall not
be held responsible for the payment of fees or charges and the school will accept billing in our (my) name only
to facilitate submission of student accident insurance claims, if applicable, or for the prompt forwarding of
billing to us (me).

This document is intended to be a release to those obtaining and supplying medical treatment (emergency &
non-emergency), including Jenison Public Schools, any members of the school’s administration or staff, its
employees, and any physicians or institutions treatment or offering medical assistance to the student.

Mother/Guardian Signature Date

Mother/Guardian Name (Please Print)

Home Phone Work Phone Cell Phone

Father/Guardian Signature Date

Father/Guardian Name (Please Print)

Home Phone Work Phone Cell Phone

*Electronic/Typed signatures constitute acceptance of terms stated above

 International Student Application

POWER OF ATTORNEY & FINANCIAL SUPPORT

FOR MINORS STUDYING IN THE UNITED STATES
Student:
Family name Given name(s) Citizenship Date of birth: Sex
□M □F

Name and address of school in US:

Jenison High School, 2140 Bauer Road, Jenison, MI 49428

Address where student will reside in US

Not yet available

Parents/Guardians:
Parent 1: Parent 2:

Full Name: Family Name Given Name Family Name Given Name

Date of Birth:

Home Address:

Telephone
Number:

Power of Attorney:
Family Name: Given Name(s) Status： Date of Birth:
Morse Crystal
§ American citizen
□ Permanent resident
Telephone Number:
Current Residential Address:
616.889.4800
912 Golfside Ct, Jenison, MI 49428

Our child will reside：

□with the appointed guardian □ with another person.
I/we ______________ __________ _____and ____________________________ ,the parents/guardians of the said student(s),
____ ______ _________________ , during their stay in the United States, while he/she is under age, have made necessary arrangements
that the power of attorney should act in the place of the parents. By signing this agreement, I/we affirm that I/we have appointed the power of
attorney named above, which resides within a reasonable distance of my/our child’s intended residence, and the school, and will be able to
fulfill his/her obligations as a guardian in the events of an emergency.
This agreement includes that I/we, the natural parents, agree to provide financial support for the student(s) estimated living expenses for a
minimum of $6,000 per student.

Signature of Parent 1: Date:

Signature of Parent 2: Date:

*Electronic/Typed signatures constitute acceptance of terms stated above

 International Student Application

Parent Agreement (p 1 of 6)

Parent Agreement

This agreement outlines the regulations and policies of Jenison Public Schools (JPS) and/or Hola Universal Studies
Abroad (Hola USA). The Custodial Advisor (CA) will work on behalf of Hola USA to oversee students within the greater
Jenison area while attending Jenison High School, and act as their local Guardian. Please read this document carefully.

Application

We, the Natural parents confirm that our son/daughter has personally filled out the student portion of this
application (including the student letter and all profile information). We agree to provide truthful answers on the
Student Application documents, in addition we agree that we:

• Will truthfully report all information to JPS and Hola USA regarding the scope and nature of any special health
problems, including current medical conditions and all allergies.
• Notify JPS and Hola USA in writing if a student is vegetarian or has food restrictions or allergies, has received
treatment for eating disorders or mental health problems and/or has had any other past health issues.
• Provide Hola USA and JPS with a signed Statement of Health evaluation provided by a certified doctor, including
all immunizations. The Statement of Health will be filled out by a licensed physician and will be signed and dated
by that physician. JPS and Hola USA require an address and phone number of physician.

Private Arrangements
• Students and/or natural families may not initiate direct contact with JPS unless it is after the visa has been issued
and strictly for the purpose of choosing classes, or interviews as part of the application process. Initiated contact
will be considered a breach of contract.
• Private arrangements with host families and or schools are a violation of contract resulting in termination from the
JPS program without a refund of program fees.
• Students and/or natural family who decide to find a new school and or family at the semester break or during the
school year are considered to be voluntarily dropping the JPS Program and are not eligible for a refund of
program fees. In addition, the F-1 Visa issued by JPS will be terminated. JPS will no longer sponsor said student.

English Proficiency
If a student does not possess sufficient English to function in a U.S. High School, JPS reserves the right to deny
enrollment into the program. JPS will not reimburse program fees for students who have been denied enrollment based on
lack of English.

School Guidelines
• Students attending high school on an F-1 Visa must adhere to the Federal guidelines as well as obey all school
rules and regulations as outlined in the JPS Student Handbook and JIA International Student Handbook.
• JPS is not responsible for a replacement family if the student is not adjusting appropriately to his/her host family
or is creating difficulties for the host family.
• While the United States of America and its communities are very safe by world standards, I/We understand that
the host family will generally supervise both at school and my/our child, but such supervision will not be
constant.

*Electronic/Typed signatures constitute acceptance of terms stated above

 International Student Application

Parent Agreement (p 2 of 5)

Student Guidelines Continued…

• I/We give permission for my/our child to take part in all programs and activities sponsored by JPS. This includes
school field trips and recreational activities organized by the CA and/or JPS staff.
• I/We permit Hola USA and JPS to use photographs or images of my/our child in promotional materials.

Student Financial Responsibility

• Additional Fees Assessed by Schools
o The initial enrollment fees are outlined in the International Student Program-Tuition & Fee Agreement.
o Schools may have various fees throughout the year for field trips, labs, lunch programs, computers, books
etc. These fees are the responsibility of the natural parents.

• Host Family Fees

o Hola USA is solely responsible for payments to host families, local representatives and school officials
for the host fees. Please advise students NOT to give any money to host families for these fees, as host
families will be paid by Hola USA. Please do not discuss the program fees or monthly stipend amounts
with the host family.

• JPS, Hola USA nor the student’s host family will assume any financial responsibility for the acts of the student,
whether willful or negligent, including, but not limited to:
o Damage to property
o Bodily injury to themselves or others
o Lost or stolen money (students are advised NOT to carry large amounts of cash at any time)

• Medical Insurance
o All exchange students must purchase medical insurance prior to departing from his/her natural country.
Insurance must cover the minimum requirement of the U. S Department of State and provide a copy to
JPS.
o The exchange student must submit all completed medical care documents to the insurance provider and
pay any and all medical fees not covered by the insurance.
o The host family will not assume any financial responsibility for insurance issues, including, but not
limited to:
§ Paying medical bills at the time of treatment
§ Paying for medical services provided to the student by any doctor or medical facility if an
insurance claim has been denied or partially paid

• Students are responsible for purchasing their own:

o Personal hygiene items (deodorant, shampoo, soap, toothpaste etc.)
o Clothing
o Entertainment expenses
o Students must be prepared to pay for meals eaten outside the host family home, if they choose to
accompany the host family for dinner at a restaurant, they must offer to pay for their own meal.

*Electronic/Typed signatures constitute acceptance of terms stated above

 International Student Application

Parent Agreement (p 3 of 5)

Student Financial Responsibility continued…

• Computer/Tablet/Personal Electronic Devices
o Students are responsible for bringing their own computer/tablet/personal electronic devices. Host family
is not responsible for any theft or damage to said personal technology.
o JPS will provide a Chromebook that students may borrow for academic use during the school year.
o The host family, at their discretion, may not allow student the use of their personal
computer/tablet/personal electronic devices. Should the host family allow the use of their said personal
technology the student is responsible for any damage should it occur.
• Phone
o Students must bring or buy their own phone or use a phone card. Host families will NOT sign phone
contracts for students.
• Money
o Students may not borrow money from their host family or expect the host family to open a joint bank
account or lend their name to any bank account related to the student.
o Students must have an adequate monthly stipend from their natural family. It is recommended that student
arrive with enough US money to provide for themselves for at least the first two months.

• Daily transportation to and from school is not covered in program fees.

• Host family’s responsibilities are limited to room and board.

Flights / Travel
• JPS assumes no responsibility for booking or confirming flight reservations for students.
• Student may NOT under any circumstances, depart his/her country until a temporary or permanent host family
placement has been confirmed by Hola USA.
• Their host family, area representative or school official will pick up student at the airport. For arrivals and
departures, additional fees will apply if the flight arrives or departs during hours that are not convenient to the
persons picking up or dropping off the student.
• Travel outside of the country will not be allowed during the program unless JPS is notified and is able to facilitate
proper government documents prior to travel. Students who leave the US while in the F-1 program risk being
rejected at the border for re-entry into the United States. JPS is not responsible for issues regarding re-entry into
the U.S.
• Extended trips that require travel outside of the state of Michigan require written permission from natural parents
and host parents. Travel must be with an approved group, host family, or to visit person’s known to the student,
host family or natural parents. JPS must give written approval for travel.
• JPS must approve trips involving absence from school in advance.
• Every student will receive information about optional travel opportunities from JPS or CA.
• Host families are not expected to take their students on trips, they are optional.
o Students traveling with their host families should expect to pay their own way. A host family
who invites or plans a family trip with the student, should be very clear (from the earliest
planning stages of the trip) the cost of the trip.
• Students may not travel alone or with underage friends while in the U.S. without prior approval from
host parent(s).
• Students may not have friends/boyfriends/girlfriends or siblings visit during their exchange year. Parents
may only visit with prior permission from JPS and Hola USA.

*Electronic/Typed signatures constitute acceptance of terms stated above

 International Student Application

Parent Agreement (p 4 of 5)

Hygiene
Students must be instructed prior to departure of the hygiene standards in America.
• Showering and brushing teeth daily is a common practice; students must wear deodorant and keep their hair clean.
• Students must wash their clothing often and keep up their appearance. Clothes including jeans must be washed
weekly.
• Failure to comply with these guidelines may result in probation.

Student Behavior
• Exchange students are considered ambassadors for their country. Their attitude and behavior must reflect the
highest standards set by this program.
• Students must be open to new cultures, be willing to make life style adjustments and to do so understanding the
fact that they have chosen to participate in this cultural exchange experience.
• I/we understand that the U.S.is a multi-cultural country and that customs and traditions of families may be
different from my/our own country. I/we understand that discrimination, based on race, philosophy, sexual
orientation, or religion is illegal in the U.S.

Student Probation
• Probation is a warning/ trial period in which the JPS staff determines whether or not the student will make
behavioral changes deemed necessary to stay within the program. Based on information derived from incident
reports, medical records and/or letters submitted, the JPS Administration along with CA would issue a probation
letter and give restrictions and or probation terms to the student.
• Probations may be issued for the following reasons:
o Poor or failing grades
o Breaking host family rules or displaying unacceptable behavior in the host-family home
o Breaking JPS, Hola USA and/or CA rules
o Disciplinary problems in the community or school
• A probation letter outlines a very specific set of expectations of the student, while giving a time frame for
improvement.
o A copy of the written probation letter will be given to student, host family, JPS, CA and natural parents.
o JPS/ Hola USA wishes to give exchange students every opportunity for improvement. We will work with
students to resolve conflicts and/or disciplinary difficulties.
o If improvements are not made, student risks dismissal from the program.
o If a student on probation is asked to leave the host family home, JPS and CA will evaluate the
circumstances to determine if the student will be placed with another host family or will be dismissed
from the program.
o CA’s will not work at finding a new host family for students who are on probation and showing no
improvement.

Program Termination
• JPS and CA determines student termination based upon the review of incident reports, probation letters, medical
records, and the ongoing student behavior. Behavior that has been deemed unacceptable and violates rules and/or
regulations as set forth by JPS, CA, and/or Hola USA will result in dismissal.
• Students can be terminated from the JPS Program for the following reasons:
o Failure to make appropriate changes in response to probation
o Low or failing grades with no effort to improve them
o Psychiatric diagnosis, i.e. depression/psychosis
o Diagnosed eating disorder, i.e., anorexia/bulimia
o Unauthorized travel and/or permission for natural parent visits
*Electronic/Typed signatures constitute acceptance of terms stated above
 International Student Application

Parent Agreement (p 5 of 5)

Continuation of Program Termination…

o Expulsion from school

o Inability to adjust to living with an American family following a warning or probation letters
o Failure to respect and abide by JPS rules, or any other behavior discrediting JPS, the CA or Hola USA
o Failure to adhere to the Federal Guidelines for a F-1 Visa
o JPS will not refund any program fees for students who have been terminated from the school for.
o JPS is not responsible for reimbursement of any school tuition fees.

Summer Arrangements and Extension Programs

• Student or natural parents will make no summer arrangements.
• JPS and Hola USA will not allow student or natural family to arrange extension programs privately with the host
family and/or school.

Hold Harmless
• We hereby release host families, JPS, Hola USA and all of the employees, from all liability, damages or
claims which have been incurred during the program or after the termination of the program. We were
advised of all program guidelines including student rules, termination regulations and fee
reimbursement.
• We authorize the Host Family, and/or any JPS/ Hola USA personnel to act for us as an authorized
caregiver in any emergency, accident, illness, or any other situation requiring caregiver status during the
period of time the student is involved in the JPS or Hola USA Program.
• We understand that the participant will be subject to the authorities and teachers of the school where
he/she may be assigned and that he/she will have to follow the rules given by the family with whom
he/she may live.
• We understand that JPS and Hola USA reserves the right to terminate the participation in the program of
any participant whose conduct is in violation of JPS and Hola USA rules and/or Standards of Conduct,
including, but not limited to, making private arrangements for program extensions directly with a host
family and/or school. If the decision for student termination is made, the participant and Hola USA will
be formally notified and forfeit the right to any refund of program fees.

Signature of Understanding:
I hereby certify that I have read, understood, and agree to all that is contained within the Parent Agreement.

Signature of Parent(s)/Guardian(s)
Printed Name of Parent(s)/Guardian(s)

Date:

Student Name:

*Electronic/Typed signatures constitute acceptance of terms stated above