Local Representative Information Form

FOREIGN EXCHANGE PROGRAM

Full Name*

First NameMiddle NameLast NameSuffix

Foreign Exchange Organization*

Are you a new representative for this (or the coming) school year?*

YesNo

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone #1*

Area CodePhone Number

Phone Type*

HomeCellWork

Phone #2

Area CodePhone Number

Phone Type

HomeCellWork

Phone #3

Area CodePhone Number

Phone Type

HomeCellWork

E-mail Address*

Supervisor's Name*

First NameLast Name

Supervisor's Title*

Supervisor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone #1*

Area CodePhone Number

Phone Type*

HomeCellWork

Phone #2

Area CodePhone Number

Phone Type

HomeCellWork

Phone #3

Area CodePhone Number

Phone Type

HomeCellWork

E-mail Address*

I have access to a copy of the Clark County School District’s Foreign Exchange Program Handbook found on the Foreign Exchange Program Web site at: Foreign Exchange Program

My electronic signature below indicates that I agree to abide by all policies regarding foreign exchange students. I further agree to inform prospective students and host parents of the contents of the above-mentioned document.

In addition, I recognize that as an approved representative of the Clark County School District, I am responsible for the following: (Please check each of the following boxes.)*

Ensure that within two weeks of enrolling, all host parents have submitted the appropriate arrival paperwork to the Foreign Exchange Office.Notify the Foreign Exchange Office within 24 hours of any changes in student host parents, contact information, or placement status, etc.Adhere to all deadlines for student application. (Fall Semester – 4:00 p.m., second Friday in July, Spring Semester – 4:00 p.m., second Friday in December)

All new representatives must participate in a 30-minute orientation at the CCSD Foreign Exchange Office prior to being allowed to place and/or sponsor students in the District. Please contact the office at (702) 799-8441 or email to chalmic@nv.ccsd.net within the next two working days to schedule an orientation.

Representatives who have not placed students in the District within two school years will also be required to attend an orientation session.

*

I have read this policy and understand it.

ELECTRONIC SIGNATURE: Please type your first and last name*

A confirmation receipt of this application will be sent to the e-mail address you provide here:*

Confirmation Email