ESL Summer Camp: June 18 July 27, 2012 Homestay Application (Please answer all questions completely) Family Name (Surname) First Name (Given name) Applicant s Complete Address Male: Female: REGISTRATION DEADLINE MAY 18, 2012 Email (Required): Telephone: SELECT THE LENGTH OF STAY YOU ARE APPLYING FOR: Birthday (Required): / / Month Day Year 4 weeks = $1200 5 weeks = $1400 6 weeks = $1600 What is your English speaking level? High Medium Low DO YOU SMOKE? Yes No REQUIRED: List your five favorite hobbies and interests. (All five MUST be completed.) 1) 2) 3) 4) 5) Do you have any medical allergies? No Pets Food Specify: REQUIRED: Please describe the members of your personal family. Select all boxes that apply to your family: Mother Occupation: Father Occupation: Sister(s) - Age(s): Brothers(s) - Age(s): Pet(s): Have you ever visited the U.S. before? No Yes, where: Please describe current medical condition, and list any prescription medications that you are currently taking: Signature: I verify that the information on this form is true and correct to the best of my knowledge. Applicant Signature Parent Signature Indemnification: Student fully indemnifies Diablo Valley Homestay LLC and it s agents and employees from any claim arising from Student s conduct. Student understands that hosts are not employees or agents of Diablo Valley Homestay LLC, and student assumes all risk associated with injury or loss arising from the living in the homestay, including behavior of hosts. Student releases Diablo Valley Homestay LLC of any liability for any claim of injury, death, property damage or other loss. Student will not institute a claim against Diablo Valley Homestay LLC and will release and hold Diablo Valley Homestay LLC forever harmless for any and all claims arising from living in the homestay, including the behavior of hosts. Limitation of Liability: In no event shall Diablo Valley Homestay LLC have any liability to the student for any indirect, special, incidental or consequential damages, however caused, and under any theory of liability, whether or not Diablo Valley Homestay LLC had prior knowledge of the possibility of such damages. Further, Diablo Valley Homestay LLC shall not be named as a party, called as a witness, or served discovery requests in any dispute between student and host regarding the financial dealings between student and hosts. Mediation/Arbitration: In the event any dispute arises with respect to the services provided by Diablo Valley Homestay LLC, and such dispute cannot be settled through direct discussions, then Diablo Valley Homestay LLC and Student agree to first endeavor to settle the dispute by mediation administered by the American Arbitration Association under its Commercial Mediation Rules, before resorting to any other means of dispute resolution. Following at least one such mediation session, any unresolved dispute shall be settled by binding arbitration administered by the American Arbitration Association in accordance with its Commercial Rules, and the judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Further, in the event of any such arbitration, the prevailing party shall be entitled to costs and attorney's fees. PLEASE SEE PAGE 2 FOR PAYMENT AND MAILNG INSTRUCTIONS Email: info@diablovalleyhomestay.com Phone: 1-925-876-0080 Fax: 1-925-274-1008 www.diablovalleyhomestay.com Diablo Valley Homestay LLC Page 1
PAYMENT AND MAILING INSTRUCTIONS Step 1: SELECT THE LENGTH OF STAY YOU ARE APPLYING FOR: 4 weeks = $1200 5 weeks = $1400 6 weeks = $1600 (Rates include homestay placement fee, three meals per day, all utilities, internet access*, and transportation to/from school daily.*students will need to bring their own computers.) Step 2: Read and sign the following two forms: Homestay Program Participation Agreement and Liability Release for Underage Students Step 3: Prepare a check or money order (no credit cards accepted) for the full amount of your ESL Summer Camp homestay expenses (4 weeks = $1200, 5 weeks = $1400, or 6 weeks = $1600). Make checks payable to Fia Parker. Step 4: IMPORTANT: If you are also enrolling at Quarry Lane for the regular 2012-2013 school year, please include an additional $250 Homestay Continuation Fee. PAYMENT WORKSHEET Make checks payable to: Fia Parker 4 weeks 5 weeks 6 weeks ESL Summer Camp Only Total Amount Due: $ 1200 $ 1400 $ 1600 ESL Summer Camp AND 2012-2013 School Year (Add $250) Total Amount Due: $ 1450 $ 1650 $ 1850 Step 5: Mail the following required items: 1) Homestay Application (5 pages), and 2) Homestay Expenses Check, to: Fia Parker Diablo Valley Homestay 246 Golf Club Road Pleasant Hill, CA 94523 Please make sure every question on the Homestay Application has been fully completed, otherwise processing will be delayed. Cancellation Policy REGISTRATION DEADLINE MAY 18, 2012 1. Applicants who cancel their homestay request before May 18, 2012, will receive a refund of their homestay expenses, less $250 processing fee. 2. Applicants who cancel their homestay request after May 18, 2012, and before June 8, 2012, will receive a refund of their homestay expenses, less $450 processing fee 3. No refunds will be given for cancellation requests received after June 8, 2012. ARRIVAL INFORMATION: Airlines: Flight Number: of arrival: Time: Airport: How will you get from the airport to your homestay? Friend/Relative Shuttle Bus Service Diablo Valley Homestay - Personal Driver Service ($120)* *Our driver will meet you in the Arrival Lobby and take you directly to your host family's home. The cost for this service is $120 per person (cash only), paid directly to the driver, at the airport. HOST FAMILY DISCLAIMER Students are not guaranteed placement with any specific type of family (race, marital status, families with children, etc.), as all of the families in our program have been pre-screened and have met the qualifications of being a host family. Your placement will be based upon a number of different criteria including the families availability at the time you arrive, the type of student they are looking to house, and the information provided in your housing application. We do guarantee that you will be placed with a family that wants to be a host family to an international student, and can provide you with good exposure to the American way of life. All students placed with host families must agree to the terms of the Homestay Program Participation Agreement, and the Liability Release for Underage Students form. A copy of each of those forms must be signed and returned with the Homestay Application, along a check or money order for the full amount of your homestay expenses. Your placement with a host family will be secured when all required items have been received. You will be sent information about your host family immediately after a placement has been confirmed. Students are expected to live in their homestay for the full program. Email: info@diablovalleyhomestay.com Phone: 1-925-876-0080 Fax: 1-925-274-1008 www.diablovalleyhomestay.com Diablo Valley Homestay LLC Page 2
Homestay Program Participation Agreement for Quarry Lane School ESL Summer Camp 2012 Please read the following participation agreement very carefully. By signing this document, you acknowledge that you understand and agree to all the terms of the document. 1. Security deposit. All ESL Summer Camp students are required to give a refundable deposit, in the amount of $100, at the time of move-in, in order to cover the cost of any damages done to the host family s property by the student while they are living in the home. This $100 security deposit is refundable, and will be given back to the student at the time of departure, providing it does not need to be used to pay for any damages caused by the student. Therefore, please be prepared to give your host family the $100 refundable security deposit on the day that you move in to the homestay. 2. Additional damages. I understand that if any damages caused by the student exceed $100, I will pay the full cost of the repair or replacement, including any amount which exceeds the $100 security deposit initially given to the host family. By signing this agreement, both student and their parent/legal guardian agree to pay the full cost of any damages (both intentional and unintentional) caused by the student while living in the homestay. 3. Host family selection. California is an extremely diverse state and unlike any other in the United States. In particular, the San Francisco Bay Area is one of the most diversified areas in the United States. Diablo Valley Homestay (DVH) does not discriminate against any host families in our registry based on age, race, color, religion, gender, national origin, sexual orientation, disability, and marriage or family status. To do so, would be against the law. Our host family registry is made up of a many different populations, including African, Asian, Filipino, Indian, Hispanic, European, and Caucasian families. Regardless of their ancestry, all of these families are English-speaking. I agree to not make any judgments about different cultures, and instead, to be open to a positive relationship and cultural exchange with my host family regardless of their personal characteristics or native origin. 4. Meals. I understand that my host family is responsible for providing my meals while I am in the homestay. The host family will supply basic continental breakfast items. I am responsible for preparing my own breakfast every day. The host family will supply basic lunch items and I am responsible for preparing my own lunch every day. The host family will provide dinner for the entire week, although the host family will be responsible for preparing dinner only for the majority of the week. If the host family is not home for dinner, then I am responsible to prepare my own dinner, using the food provided by the host family. I understand that I am responsible for purchasing any snack food items that I wish to have. (The host family will take the student to the grocery store, so that the student may purchase any additional snack food items.) 5. Housework. I understand that I will be treated as a member of the family while I am living in the homestay. Therefore, I accept that I will be expected to help the family with basic household chores, such as keeping clean the following areas that I use: bedroom, bathroom, kitchen, and other common areas that I spend time in. I understand that my host family is not my servant or maid, and that I am completely responsible for my own housekeeping and laundry. 6. House rules. I agree to follow the house rules set by the host family. I understand that the host family has the right to ask me to leave their home if I do not follow the house rules. I further understand that DVH will not place me in another homestay if I am removed from the home due to disciplinary or behavioral problems (including breaking house rules, theft of property, continuing conflicts or verbal abuse toward a family member, physical abuse to any persons or property, etc.). Students who are removed from a homestay due to disciplinary or behavioral problems will not receive any refund of rent that has been paid for the remainder of the program. 7. Medical issues. I agree that I will have full health (medical and dental) coverage while living with the host family. In the event of an emergency, the host family has the right to authorize emergency medical and dental treatment for the student. I will provide my host family and DVH with my medical insurance information, including the name of my insurer, as well as my policy number. 8. Guardianship. I will have an approved U.S. guardian while living in the homestay. I will provide my host family and DVH with the necessary contact information for my approved U.S. guardian. The host family will not serve as the guardian of the student. 9. Cell phones. I will purchase and be responsible for a cell phone while I am living in the homestay. I will make and receive all phone calls on my own cell phone, instead of the host family s telephone. I understand that I will be required to tell my host family my telephone number so that they can contact me if necessary. 10. Curfew. I agree to come home every night before the designated curfew time given to my by the host family. (Example: If the host family sets a 10:00pm curfew time, then the student must be home every night by 10:00pm.) Diablo Valley Homestay LLC Page 3
11. Internet access, computers, and printers. Every homestay has Internet access available. I will be responsible for using my own computer in the homestay. 12. Smoking. I will not smoke inside my homestay, nor will I smoke anywhere on the outside property of the host family. I understand that the host family has the right to ask me to leave their home if I smoke anywhere on their property. 13. Illegal activities. I will not engage in any illegal activities while living in the homestay. I understand that the host family has the right to ask me to leave their home if I engage in any illegal activities while living in the homestay. 14. Problems in the homestay. I will bring any concerns, issues, or complaints about my homestay to DVH immediately. I will do my best to work together with DVH and my host family to resolve any problems that occur while I am living in the homestay. 15. Duration of placement. I understand that I am expected to live in my homestay for the entire length of the ESL Summer Camp program, unless otherwise directed by DVH. 16. Early arrival and late departure from homestay. Extra days in the homestay. Students are allowed to move in to the homestay 1-3 days before the ESL Summer Camp begins on June 18. Therefore, you may move in to the homestay between June 15-17. Students should move out from the homestay 1-3 days after the ESL Summer Camp ends on July 27. Therefore, the student should plan to move out between July 28 30. Please understand that the Homestay Expenses check you submit with this application will only cover the period of the ESL Summer Camp (June 18 July 27). Each additional night in the homestay (either before June 18, or after July 27), will cost $30 per night. That amount must be paid directly to the host family by the student, upon arrival at the homestay. After your flight reservation is made, please send us the flight arrival and departure details, and we will calculate the fee for the additional time in the homestay. 17. Last day in the homestay. I will clean my bedroom and bathroom to my host family s satisfaction. I will also provide my forwarding address to my host family so they can return my security deposit within the 21-day period allowed by California law. 18. Attending Quarry Lane for the 2012-13 school year. If the student completes the ESL Summer Camp and is enrolled at Quarry Lane for the 2012-2013 school year, they may continue to live in their homestay after the end of the ESL Summer Camp. They must follow all rules of the regular homestay program, including agreeing to all terms and conditions of the program. (Additional forms will be sent to the student, if he/she indicates that he/she has enrolled at Quarry Lane for the 2012-2013 school year.) 19. Indemnification. Student fully indemnifies Diablo Valley Homestay LLC and it s agents and employees from any claim arising from Student s conduct. Student understands that hosts are not employees or agents of Diablo Valley Homestay LLC, and student assumes all risk associated with injury or loss arising from the living in the homestay, including behavior of hosts. Student releases Diablo Valley Homestay LLC of any liability for any claim of injury, death, property damage or other loss. Student will not institute a claim against Diablo Valley Homestay LLC and will release and hold Diablo Valley Homestay LLC forever harmless for any and all claims arising from living in the homestay, including the behavior of hosts. 20. Limitation of liability. In no event shall Diablo Valley Homestay LLC have any liability to the student for any indirect, special, incidental or consequential damages, however caused, and under any theory of liability, whether or not Diablo Valley Homestay LLC had prior knowledge of the possibility of such damages. Further, Diablo Valley Homestay LLC shall not be named as a party, called as a witness, or served discovery requests in any dispute between student and host regarding the financial dealings between student and hosts. 21. Mediation. In the event any dispute arises with respect to the services provided by Diablo Valley Homestay LLC, and such dispute cannot be settled through direct discussions, then Diablo Valley Homestay LLC and Student agree to first endeavor to settle the dispute by mediation administered by the American Arbitration Association under its Commercial Mediation Rules, before resorting to any other means of dispute resolution. Following at least one such mediation session, any unresolved dispute shall be settled by binding arbitration administered by the American Arbitration Association in accordance with its Commercial Rules, and the judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Further, in the event of any such arbitration, the prevailing party shall be entitled to costs and attorney's fees. The student and his or her parent/legal guardian acknowledge that they have carefully read this Agreement and agree to be bound hereto. _ Student Signature _ Print Student Name _ Signature Print Name Diablo Valley Homestay LLC Page 4
Homestay Liability Release for Students Under Age 18 The following liability release is for students under the age of eighteen (18) who request to be placed in a homestay by Diablo Valley Homestay LLC (DVH). The student and their parent(s) must sign this form prior to the student being placed in a homestay. We request to have our child,, placed in a homestay by DVH. We acknowledge that our child is under the age of eighteen (legal adult status in the United States), and that we - not the host family, nor DVH will be held responsible for our child s actions while he/she lives in the United States. We agree to hold harmless and release all liabilities of DVH, and the host family chosen to host our child, including all claims against DVH and the host family for any injury, loss, damage, accident, delay or expense resulting from participation in the homestay program. We hereby acknowledge, accept, and agree to the above named terms and conditions. Student I, agree to live in the chosen homestay at my own risk and liability. I also agree to hold harmless and release all liabilities of DVH and the chosen host family, including all claims against DVH and the host family for any injury, loss, damage, accident, delay or expense resulting from participation in the homestay program. I hereby acknowledge, accept and agree to the above named terms and conditions" Student Name Diablo Valley Homestay LLC Page 5