STUDENT PHOTO 100 East Florida Avenue, Melbourne, FL

STUDENT PHOTO 100 East Florida Avenue, Melbourne, FL 32901 321-727-0793 www.melbournecc.org 2012-2013 INTERNATIONAL STUDENT APPLICATION FORM Personal Data Last Name: First Name: Middle Name: American Name (if any): Date of Birth: Month Day Year Street Address: City: Male Female State/Province: Country: Postal Code: Home Phone: Email: City and Country of Birth: Country of Citizenship: Father s Name: Work Phone: Occupation: Mother s Name: Work Phone: Occupation: Guardian s Name: Work Phone: Occupation: Educational History Current Grade: Name of Current School: Applying for Grade: Please indicate if student is willing to enter into a lower grade to meet the requirements of the specified school? Yes No

NOTIFY IN CASE OF EMERGENCY: (other than parent or guardian) Name: Telephone: Relationship to student: Address: Physician s Full Name: Telephone: Address: To whom should bills, reports, etc., be sent? Address: As a parent (guardian), I the undersigned, agree to pay tuition and fees, and comply with all other policies while my child is attending Melbourne Central Catholic High School. I also agree to give my time, interest, and finances to Melbourne Central Catholic High School to the best of my ability. Signature: Date: I promise to know the rules and regulations of Melbourne Central Catholic High School and abide by them. I also promise to be active in extracurricular activities since it is the philosophy of the school to build the total community of the school, family and church. I want to be at Melbourne Central Catholic High School. Student Signature: Date: Have you ever been charged with or subject to disciplinary action for scholastic or any type of misconduct while attending any previous school? Yes No If yes, please explain on a separate sheet of paper and attach to this application. REQUIRED SCHOOL RECORDS: Incoming 9th Grade Only All other students 7th & 8th grade semester averages Official transcript from previous high school and proof of 8th grade promotion STATE REQUIREMENTS Florida state law requires that you complete and submit an HRS 680 Immunization Form prior to admittance. Students moving from out of state must submit a health examination form. You are also required to submit an original birth certificate (for a file copy to be created) and a copy of the student s visa and passport. AUTHORIZATION STATEMENT AND SIGNATURE I authorize Melbourne Central Catholic High School to release the records of (Name of Student) to institutions requesting them for acceptance into colleges, other high schools, military, or business firms. Signature of Parent or Guardian: Date:

MELBOURNE CENTRAL CATHOLIC HIGH SCHOOL STUDENT RECORD REQUEST 100 East Florida Avenue Melbourne FL 32901 PHONE: 321-727-0793 FAX: 321-727-1134 Current School: Address: Country: Please send a complete transcript for Birth date: WE ASK THAT THE FOLLOWING INFORMATION BE INCLUDED 1. Original certified transcript along with certified translated English transcript. 2. Units and grades earned to date (indicate any courses which are HONORS or AP). 3. Key to grading system. (Please give numeric equivalent for letter grades as A=100-94, B=93-85, etc.) 4. Course content, i.e. specify American History, Biology, Algebra I, etc.; not Social Studies, Science, Math. 5. Date of withdrawal from your school. 6. Grades to date of withdrawal. 7. Standardized testing, psychological testing, and education plans. 8. Copy of TOEFL and/or SLEP scores. 9. Health records, including HRS 680 for Florida schools, immunization records for schools outside of Florida. Thank you for your assistance. I hereby authorize the release of all records of my child/myself. Signature: Date:

MELBOURNE CENTRAL CATHOLIC HIGH SCHOOL International Student Tuition & Fees Contract 2012-2013 STUDENT INFORMATION Student Last Name: First Name: American Name (if any): Date of Birth: Nationality: PARENT INFORMATION Father/Mother Last Name: First Name: Billing Address: City: Country: Zip: Telephone: Fax: Email: TUITION AND FEES Tuition Fees: US $43,500 (See fees schedule for details) SCHOOL ACCOUNT INFORMATION Wire payments to: Melbourne Central Catholic High School, 100 East Florida Avenue, Melbourne, FL 32901 Bank Swift Code: PNBPUS33 Bank Name: Wachovia Account Number: 2161020006468 Routing Number: 063000021 By signing this agreement, I understand and agree to the payment of US $43,500, I understand and accept all of the policies of the Student Handbook (copies of the Student Handbook are available on the school website: www.melbournecc.org) Parent Signature: Date:

MELBOURNE CENTRAL CATHOLIC HIGH SCHOOL International Students: New Student Breakdown of Expenses 2012-2013 School Year Tuition, Room, Boarding and Fees*: $43,500 Includes: Academic Tuition for one year and Book rental fees Academic Fees ESL fees School Lunch fee Locker and Lock Rental Fee Housing for 10 months, meals and transportation to school International Student Fee Administration Fees o Application Fees o SEVIS fees o Re-Enrollment fees Miscellaneous Fees Travel & Event Activities Fee Athletic Fees Yearbook Fee *Fees do not include uniform fees, personal pocket money, phone calls and personal belongings. -School uniforms are required and may cost $200 - $300, depending on what the student purchases. Student must purchase uniforms within the first two days after arrival. -Recommended personal spending money: $150 - $200 per month. -Payment Expectations: $5,000 with application -Remainder payable 8 weeks before arrival (June 8 th, 2012). Late fee of $750 will apply if not received by this date.

MELBOURNE CENTRAL CATHOLIC HIGH SCHOOL FINANCIAL & POLICY AGREEMENT ENROLLMENT CONTRACT 2012-2013 SCHOOL YEAR Parents, guardians, or other persons responsible for the payment of the tuition and fees of a student enrolling in Melbourne Central Catholic High School should read all the provisions of this contract, complete the required information, sign, date and return it to the Business Office. A student cannot be registered or accepted for admission until this contract has been submitted. Please be sure to fill out the entire contract and sign where indicated. Nothing in this contract limits, in any way, Melbourne Central Catholic High School s ability to enforce or apply its policies and procedures. A deposit of $5,000 is required with the application once the student is accepted. If the student s visa is denied for any reason, the deposit minus the $500 application fee will be refunded within 20 working days. Once the student is accepted, Melbourne Central Catholic High School will issue an I-20 which will be sent to the student or agent directly. The family will then be responsible for the balance of the fees and tuition. All fees and tuition must be paid at least eight (8) weeks prior to the student beginning school at Melbourne Central Catholic High School. A late fee will be assessed if not received by this time. Refund Policy: a) If a student withdraws from Melbourne Central Catholic High School, written notice must be received by the school two weeks prior to the withdrawal date. b) If a student withdraws before August 31, only boarding fee may be refunded on a prorated basis. c) If a student withdraws, is expelled, or is asked to leave after August 31, the full tuition will be due in full, regardless of the withdrawal date. This policy also applies to the second semester with a cutoff date of January 31. d) Withdrawal of a student will not cancel any accrued indebtedness. e) All fees are nonrefundable. CONTRACT ACCEPTANCE I have reviewed the enrollment contract and agree to abide by the provisions of the contract and all materials incorporated in it upon acceptance into the school. I further agree to all policies and procedures stated in the Student Handbook (available online at www.melbournecc.org). Father/Legal Guardian: Date: Mother/Legal Guardian: Date: Financially Responsible Party: Date: (If someone other than parent or legal guardian)

Medical Information Medication will be stored properly in the original container under lock and key in the designated office. There shall be no liability for civil damages as a result of the administration of such medications. I HEREBY GRANT PERMISSION TO THE PRINCIPAL OR DESIGNEE TO ASSIST IN ADMINISTERING THE FOLLOWING MEDICATION TO MY CHILD: Child s Name: Name of Medication/Drug Dosage Time Please check if either statement applies to your child s medication: Medication needs to go home each night. Medication must be kept refrigerated. Why is this medication needed during the school day? Does the student have any physical disabilities including allergies, epilepsy, eye, or ear problems, or limitation of normal activities? No Yes If yes, please explain and attach doctor s documentation Does student have any learning disabilities? No Yes If yes, please explain and attach a copy of IEP & Psychological Reports

Melbourne Central Catholic High School Medical Care and Liability Release In case of illness, accident or injury, we grant permission to examine and threat our child, whose signature appears below, at an appropriate medical facility and to make referrals to outside physicians and facilities as indicated. We grant permission to release information regarding our child s health to the assigned hose parent or the President of Melbourne Central Catholic High School. We also grant permission for our child to received any and all immunization(s) required for participation in an academic program. We understand we must pay for any necessary immunizations. While under the sponsorship of Melbourne Central Catholic High School Host Home program, the student may not participate in skydiving, hand gliding, glider riding, parachute jumping, parasailing, jet skiing, hot air ballooning, scuba diving, bungee jumping or any other high risk activity as determined by Melbourne Central Catholic high School. In anticipation of my son/daughter s acceptance to participate in the International Studies program sponsored by Melbourne Central Catholic High School we undersigned parents/guardians hereby release Melbourne Central Catholic High School, its Administrators, Board of Directors, the Diocese of Orlando, Agents, Host Families and Academic Institutions from any and all current and future claims, charges, costs, and/or causes of action for loss of property, personal injury, illness, accident or death sustained by my child during the time he/she is in the program whether covered by current insurance or not. I further agree to indemnify and hold harmless all of the above named from any and liabilities, including liabilities to third parties, which may arise from my child s participation in the program, including all activities specified herein, in the student handbook and elsewhere. We, the undersigned, acknowledge that it is our responsibility to provide adequate health insurance that can be accessed and is valid while in the United States and that we are financially responsible for any medical services that are not covered by the health insurance we provide for our child. We, the undersigned, grant Melbourne Central Catholic High School permission to use photographs and any other materials in which the participant appears for promotion or publicity of future programs. We understand that our child must bring a copy of their medical history or injections and inoculations with them whey arrive for the program. We certify that the medical information we provided on the host family application is complete to the best our knowledge and that Melbourne Central Catholic High School is not responsible if new or recurring conditions develop while participating in the program. In the event that the school determines a health issue, accident or injury or a behavior to be serious, termination of the program can occur and the student be returned home. In the event that the situation resulted from incomplete or incorrect information or a student s unwillingness to follow the guidelines of the program, no refund of fees will occur. This agreement covers the period from the time our child boards transportation to Melbourne Central Catholic High School until the student departs the host family and boards transportation Signature of Father/Legal Guardian Print Father name Date Signature of Mother/Legal Guardian Print Mother s Name Date Signature of Student Print Student s Name Date

Foreign Student Information to Obtain an I-20 Student: School to Attend: Appointment: Check off when completed 1. Diocese Information Form (with the following information) a. The designated foreign student advisor/school administrative personnel will complete the Diocese Information Form. b. The school s designated foreign student advisor/school administrative personnel must sign and date. Student required to sign if over 18 years of age. c. The school must indicate that the registration fee has been paid in full AND/OR the tuition for the year has been paid in full (this is found on the bottom of the back page of form). d. If all tuition and fees are paid in full, financial backup (ex. bank statements, etc.) will not be required. However, the foreign student advisor/school administrative personnel will be required to attach a letter to the Diocese Information Form, on school stationary, stating everything has been paid in full for the upcoming school year. Either the principal or bookkeeper must sign this letter. 2. The student must have an acceptance letter from the school he/she will be attending, with the tuition clearly stated on the letter, the year attending, and the grade level. 3. Copy of completed school registration form 4. A copy of the student s passport 5. A document from the student s family stating that the guardian (if student not living with parents) has custody of the child/this letter must be notarized as it is a legal document 6. Parent or guardian must sign and print signature; print address, city, state and date on line number 11 on the I-20 Comments:

Standardized English Test Results Please make sure to include the graded version of the SLEP test. When submitting a TOEFL result, an official copy is preferable. SLEP Yes No Date taken: Score: TOEFL Yes No Date taken: Score: Other: Date taken: Score: English Language Experience How long have you studied English in school? years Have you ever studied English in a language school? Yes No Have you ever lived in an English speaking country? Yes No Is so, then how long? Have you ever studied or are you studying on a J-1 visa exchange program? Yes No If so, name of school: Student Letter Please attach a short letter describing yourself, why you have chosen to pursue your academic goals in the United States, and any expectations you may have about living and studying in America. Please make sure that the letter is labeled, Student Letter and your name is clearly written at the top. Recommendations 1. English Language Teacher In order to gain a better assessment of the student s English language ability, a recommendation from the applicant s English language teacher is required. This letter should highlight the following points: the student s reading, writing, speaking and listening abilities. This recommendation should be labeled, English Teacher Recommendation. Additionally, please make sure that it is clearly noted by whom the recommendation is written and the institution from which this person comes. 2. Other In an effort to give the school the most detailed picture of the applicant, it is required that the applicant ask for a recommendation from a close teacher or friend. Please make sure the applicant s name is on top. Additionally, it should be clearly noted the relationship that this person has with the applicant. Father s Signature: Date: Mother s Signature: Date: Student s Signature:

Date: AUTHORIZATION AND LIMITED POWER OF ATTORNEY The undersigned (parent or guardian name) (student name), parent/guardian of, hereby grants the following authority and powers to Melbourne Central Catholic High School (MCC) relative to the student during the entire tenure of student's enrollment as a member of Melbourne Central Catholic High School. The term begins with the student's acceptance and continues until the time of his graduation or removal from MCC: 1. Medical Treatment. Melbourne Central Catholic High School (MCC) may seek medical treatment for students and approve such treatment for any and all medical, surgical, optical, dental, and mental health condition or injuries. Routine care not reasonably anticipated to have significant effect on the student or entail significant risk of present of future injury may be approved without prior authorization by the undersigned. Emergency treatment for conditions or injuries may be approved by MCC without prior authorization where time does not permit such prior authorization by the undersigned. If treatment decisions carry significant risks for the student, in the judgment of MCC, and time permits contact with the undersigned before treatment is undertaken, MCC will make reasonable efforts to contact the undersigned for approval. In the event that the undersigned cannot be reached with a reasonable time and MCC determines that the treatment decision should be made without further delay, it may approve such treatment. 2. Registration Forms and Other School Documents. MCC may execute on behalf of the undersigned the standard forms required of students as part of the registration, enrollment and class-assignment process. These forms include, but are not limited to, the Student Registration Form, the Consent to Treatment Form, the Parent Permission for Participation in Off-Campus Events Form, the Honor Code acknowledgement form and the Athletic Emergency Information Form. In addition MCC may execute on behalf of the undersigned all forms necessary to select and approve the elective classes in the curriculum for the student. 3. Athletics, Activities and Field Trips. Many athletic pursuits, activities and field trips sponsored by MCC and/or its personnel typically require the approval of a parent or guardian and may also involve the payment of fees on the student's behalf above and beyond tuition, board, books and supplies. The undersigned authorizes MCC to approve such athletic and non-athletic activities and trips without prior authorization of the undersigned. This authorization includes permission to transport the student to locations in and out of the state of Florida. Any other travel out of the country, including to the student's home country, require the prior approval of the undersigned. The undersigned acknowledges that all activities involve some risk of injury, whether from the activity itself or the transportation to and from the location of the activity. The undersigned authorizes MCC to exercise its good faith judgment in permitting participation in activities, even where there is a minor risk of injury to the student. Apart from school in sponsored activities, students may request permission to go off campus with other students and their families for events and activities that are not sponsored by MCC. The undersigned agrees that MCC may, in its discretion, grant or withhold permission for a student to be off campus for such purposes. 4. Authorization to Incur Expense. The undersigned is aware that the exercise of the powers and authority granted herein may involve expenses to the student and/or his parent or guardian. The undersigned approves the reasonable expenses associated with the activity, provided that those expenses do not exceed the amounts being charged to other students for the same activity or event. Any activity or event for which the charge would exceed $200.00 will not be approved by MCC for the student without advance consent from the undersigned. MCC shall not be responsible for damages or losses incurred by the student or the student's parent or guardian caused by failure of the undersigned to respond within a reasonable time to a request for approval of participation in activities or trips. 5. Release of Liability. The undersigned understands that MCC is not required to assume the responsibilities associated with this AUTHORIZATION AND LIMITED POWER OF ATTORNEY, and may instead require the undersigned to make every decision and execute every form and document associated with attendance at MCC as a precondition to the student s enrollment and participation in the activities and events that occur on and off MCC campus. The undersigned understands that the willingness to exercise the authority granted herein is an accommodation to the student and the undersigned for which MCC receives no additional consideration. In exchange for the willingness of MCC to exercise the authority and powers granted herein the undersigned release(s) MCC and its current and former related and/or affiliated entities, officers, trustees, agents, employees and assigns from any and all liability arising from the exercise of the powers granted herein, even if later events prove the decisions made by MCC to have been unwise when made.

6. Agreement to Reimburse Expenses and Charges. The undersigned agrees to pay for medical insurance on the student and to furnish MCC with information required to purchase medical insurance. The undersigned further agrees to reimburse to MCC any and all charges approved by MCC for any treatment not covered by medical insurance, as well as for the cost of any activity or trip in which the student participates or fails to participate at a time when the cost cannot reasonably be avoided. The charges incurred for such treatment or activities/trips shall be treated as tuition and board for all purposes. The student will not receive transcripts or graduate from MCC while any balance remains outstanding on such charges. 7. Appointment of Melbourne Central Catholic High School as Attorney in Fact. The undersigned appoints MCC attorney-in-fact for the undersigned for the sole purpose of carrying out the authority granted by the undersigned to MCC in this agreement. This power may be exercised by the Chief School Administrator, the School Nurse, the School Principal, and any Administrators. The Chief School Administrator may, in his discretion, delegate his power granted herein to any other agent or employee of MCC who, in the opinion of the Chief School Administrator, is an appropriate representative of MCC to exercise the authority granted herein for the benefit of the student. 8. Form of Written Approval. When written approval of the undersigned is required under this document or for any other purpose, MCC may accept as evidence of written approval and/or permission communications sent by conventional mail or by email or fax from the following addresses/phone numbers: The undersigned understands and agrees that permission forms or documents sent from these addresses/fax numbers will be conclusively presumed to have been sent by the undersigned and to be valid documents with or without the use of secure electronic signatures. 9. Copies of Forms and Documents Executed Pursuant to this Authorization. When documents are executed by MCC pursuant to this document, MCC will endeavor to promptly send copies to the undersigned. Unless otherwise specifically instructed, MCC will send copies by email at the address provided by the undersigned in paragraph 8, above. Parent s Signature Date Parent s Signature Date VERIFICATION OR CERTIFICATE OF ACKNOWLEDGEMENT EXECUTED BY A NOTARY PUBLIC OR OTHER LEGALLY- AUTHORIZED OFFICER OR AGENT UNDER THE PARENT S LOCAL LAWS AND/OR REGULATIONS. COUNTRY OF STATE OF COUNTY/CITY OF This document was acknowledged and executed before me, an authorized officer, legal authority, or Notary Public, on (date) by [print names of all parties executing this agreement], who acknowledged and confirmed that s/he understands the English language and the contents, terms, and conditions of this Custody Agreement. (Seal) (Signature of Notary or Other Authorized Public Officer) Notary Public/Authorized Officer for the State/City/County of My Commission expires:

Custody Agreement Date: Student s Name: I, give and assign custody for my child (Print Parent Name), to (Print Child s Name) (Host Family) Palm Bay, Florida, for providing a residence and transportation and for (Host Family City) all matters that might require a parent s approval. This custody agreement is in effect for the duration of the time my child is a student at Melbourne Central Catholic High School. (School Name) In the event that a change in the Host Family is necessary, as determined by the Host Family or the School s President, I authorize the school President, Michael Burke, to make (Print School President s Name) the necessary decisions with respect to placing my child with another Host Family and this custody agreement and authority will transfer to the new Host Family with full force and effect. I understand that I will be informed of any changes in the Host Family PRIOR to the change being made and my approval will be sought. By signing this agreement and approving any assignment to another Host Family, I hereby waive any claim against the President or the School for making a Host Family available for my child. This custody agreement will travel with my child to any subsequent Host Family to which my child is assigned by the President of the School. I understand that this form needs to be notarized or legally verified according to local law, and brought to the United States with the original signatures when my child arrives in the United States. Parent s Signature Date Parent s Signature Date VERIFICATION OR CERTIFICATE OF ACKNOWLEDGEMENT EXECUTED BY A NOTARY PUBLIC OR OTHER LEGALLY-AUTHORIZED OFFICER OR AGENT UNDER THE PARENT S LOCAL LAWS AND/OR REGULATIONS. COUNTRY OF STATE OF ) COUNTY/CITY OF ) This document was acknowledged and executed before me, an authorized officer, legal authority, or Notary Public, on (date) by [print names of all parties executing this agreement], who acknowledged and confirmed that s/he understands the English language and the contents, terms, and conditions of this Custody Agreement. (Seal) (Signature of Notary or Other Authorized Public Officer) Notary Public/Authorized Officer for the State/City/County of My Commission expires:

MELBOURNE CENTRAL CATHOLIC HIGH SCHOOL CONTACTS President: Mr. Michael Burke (321) 727-0793 x402 burkem@melbournecc.org Principal: Mr. Thomas Armstrong, (321) 727-0793 x101 armstrongt@melbournecc.org Guidance: Ms. Susan Riebsame (321) 727-0793 x304 riebsames@melbournecc.org Admissions: Ms. Tracy Steele (321) 727-0793 x302 steelet@melbournecc.org Business Office: Ms. Jenifer Leonard (321) 727-0793 x102 leonardj@melbournecc.org International Host Coordinator: Ms. Missie Cannon-Valencia (321) 727-0793 x249 valenciam@melbournecc.org Athletic Director: Mr. Mike Riazzi (321) 727-0793 x700 riazzim@melbournecc.org Registrar: Ms. Suzanne Goetz (321) 727-0793 x306 goetzs@melbournecc.org