Placement Change Form

FOREIGN EXCHANGE PROGRAM
Foreign Exchange Student Placement Change
Student's Name*

First NameMiddle NameLast NameSuffix
Foreign Exchange Organization*
Current Local Representative*
What information is being changed about this student? (Mark all that apply)*

Local RepresentativeNew Host FamilyHost Family Contact InformationChange in school of enrollmentWithdrawal from CCSD schoolsCancel previously submitted applicationExtension of programDouble PlacementOther
What is the effective date of this change?*

MonthDayYear
NOTE: District policies require local representatives to notify the Foreign Exchange Office within 24 hours of the change.
NEW LOCAL REPRESENTATIVE
New Representative's Name*
New Representative's E-mail Address*
HOST FAMILY INFORMATION
Change Type*

Temporary host family placementPermanent host family placement
Estimated date when a permanent family will be found.*

MonthDayYear
How many times has this student been placed in a different family this year? (Including arrival families, temporary or emergency placements, etc.)*

123 or more
HOST PARENT #1
BECAUSE THIS STUDENT HAS HAD MORE THAN TWO PLACEMENT CHANGES DURING THIS YEAR, THE LOCAL REPRESENTATIVE'S REGIONAL/AREA SUPERVISOR MUST CONTACT THE FOREIGN EXCHANGE OFFICE FOR APPROVAL BEFORE THIS CHANGE WILL BE ACCEPTED. FAILURE TO FOLLOW THIS POLICY WILL RESULT IN THE ORGANIZATION BEING PLACED ON PROBATIONARY STATUS FOR THE NEXT SCHOOL YEAR.
First Name*
Last Name*
Phone Number #1*

Area CodePhone Number
Phone Type*

HomeCellWork
Phone Number #2

Area CodePhone Number
Phone Type

HomeCellWork
Host Parent E-Mail Address
HOST PARENT #2
First Name
Last Name
Phone Number #1

Area CodePhone Number
Phone Type

HomeCellWork
Phone Number #2

Area CodePhone Number
Phone Type

HomeCellWork
Host Parent E-Mail Address
Physical Address*
City*
ZIP Code*
Does this family have a separate mailing address?*

YesNo
Mailing Address*
City*
ZIP Code*
In order to speed up the process with updating host parent information at the school level, we are asking organizations to upload copies of the new host parents' proof of identity and proof of address when a student moves to a new home. Please see the guidelines below for these items:

* PROOF OF IDENTITY: Photocopy/photograph of host parent's driver's license, passport, military ID, or other official ID with picture.

* PROOF OF ADDRESS: Photocopy/photograph of one of the following--Recent utility bill, rent receipt, residence lease, home sales contract.
Please attached the required documentation here. This change will not be approved until this documentation has been submitted.

Attach Host Parent Identity/Residency Documents

Cancelof
Is this student being placed in the home of a single host parent?*

YesNo
Date of natural parent notification*

MonthDayYear
Method of notification*
Is this student being placed in a home with another foreign exchange student?*

YesNo
What is the other student's name?*
Other student's home language*
Other student's home country*
Please attach documentation that both students and their natural parents have agreed to this double placement. This change will not be approved until this documentation has been submitted.

Attach Double Placement Documents

Cancelof
New School*
Date of withdrawal from current school.*

MonthDayYear
PLACEMENT CANCELLATION OR PROGRAM WITHDRAWAL
Date student will be withdrawn from CCSD.*

MonthDayYear
Withdrawal reason*

Student is canceling program and will not enroll in CCSDReturn to home countryMoving to a different stateMoving to a charter/public school in NevadaOther
PROGRAM EXTENSION
Student is extending the foreign exchange program and will now be going home at the end of the following semester*

FallSpring
Please upload any documents that your organization needs the Foreign Exchange office to sign in relation to this change.

Attach File(s)

Cancelof
Please explain, in as much detail as possible, the reason for this change.*
A confirmation receipt of this change form will be sent to the e-mail address you provide here:*

Confirmation Email
Should be Empty: