Application


fAirmOnT inTernATiOnAl educATiOn

ApplicAtion For Admission

Office Of AdmissiOns 2200 W. sequoia Avenue Anaheim, cA 92801 isee school code: 054196 ssAT school code: 3105 T 714.999.5055 | f 714.999.5026 www.fairmontschools.com

Application For Admission

Fairmont international education
for office use only student id # ________________________ App. received date: ____/_____/________

Office of Admissions 2200 W. sequoia Avenue, Anaheim, cA 92801 Tel 714.999.5055 | fax 714.999.5026

ApplicATiOn fee
enclosed with this application is a one-time new student application fee of $700 which will be used to process my child’s records. i understand that this fee is non-refundable.
discovercard card # mastercard visA American express security code check (check # _________ ) exp. date ____/_____ $___________________

print name on card ____________________________________________________ Total Amount

ApplicAnT infOrmATiOn
Applicant’s first name __________________________________ Applicant’s surname _________________________________ Applying for grade 7th 8th 9th 10th 11th Academic year ______________________________________ yes no female

indicate if student is willing to enter into a lower grade to meet requirements of the specified school? date of Birth ____/____/_______ current Grade ___________
month date year

student’s Age ___________

male

student’s Home country_______________________________country of citizenship_____________________________________ Home Address ________________________________________________________city ___________________________________ province _________________________________ country _____________________________ postal code ____________________ e-mail (required) _______________________________________________________________________________________________ Home phone (required) ______________________________ mobile phone (required) __________________________________

pArenT infOrmATiOn
father’s Title

Mr.

Dr.

mother’s Title

Mrs.

Ms.

Dr.

father’s first name _________________________________ father’s surname ___________________________________ mobile phone (required) _____________________________ primary email (required) _____________________________ check if billing address is same as student’s address Home Address ______________________________________ ____________________________________________________ Home phone _______________________________________

mother’s first name ___________________________________ mother’s surname _____________________________________ mobile phone (required) ________________________________ primary email (required) ______________________________ check if billing address is same as student’s address Home Address ________________________________________ ______________________________________________________ Home phone __________________________________________
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Application For Admission
required infOrmATiOn

Fairmont international education

Why would you like to come to the united states for your education? please explain. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ How did you hear about fairmont? __________________________________________________ __________________________________________________ please provide placement agency information (if applicable) _____________________________________________________ _____________________________________________________

does the student require: Housing* Transportation* medical insurance* yes yes yes no *A separate application for Homestay is required. no *Bus transportation request form is required. no *medical insurance is required. referral information is available.

u.s. mAilinG Address (student’s english speaking contact)
relationship to applicant:
Guardian father mother uncle Aunt Other (note) _________________________

first name ______________________________________ surname ___________________________________________________ Home Address ________________________________________________________________________ Apt. # __________________ city ______________________________________________________state __________ postal code _________________________ Home phone _____________________mobile phone_____________________ e-mail ____________________________________

educATiOnAl HisTOry
current school ____________________________________________ city/country ___________________________________ date entered _______________________________number of years attended _____________ current Grade ____________ Other schools attended: (please include dates) _____________________________________________________________________ dates Attended _____________________________________________________________________ dates Attended _____________________________________________________________________ dates Attended _______________________ _______________________ _______________________

Why are you thinking of leaving your present school?______________________________________________________________ Applying for i-20: yes no yes no (if yes, please attach copy of i-20)

does this student hold an i-20 from another school:

primary language spoken at home __________________________ Additional languages ______________________________
3 | www.fairmontschools.com

Application For Admission
ApplicAnT infOrmATiOn

Fairmont international education

Academic strengths: ________________________________________________________________________________________ Academic weaknesses: ______________________________________________________________________________________ Has the applicant ever been evaluated for the following? (if yes, explain on a separate sheet of paper) learning differences psychiatric/psychosocial problems Hearing problems o no o no o no o yes o yes o yes Behavioral problems visual problems i.q. o no o no o no o no o yes o yes o yes o yes (please explain)

does the applicant take any prescribed medication or need special attention?

condition ______________________________________________ medication _______________________________________ condition ______________________________________________ medication _______________________________________ Have there been any situations in the applicant’s life that the school should know about in order to meet his/her learning or developmental needs? (i.e.: frequent changes of school, death in the family, divorce, etc.) ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Has the student ever been subject to major disciplinary action in any school? o no check all activities the student would be interested in: o yes (please explain)

? ? ? ? ?

football Basketball soccer Baseball softball

? ? ? ? ?

cross country/Track Golf volley ball Tennis cheer leading

? ? ? ? ?

speech & debate drama choir/show choir Band Orchestra

? ? ?

yearbook school newspaper student Government/ AsB

pArenT AGreemenT
i certify that all information given in the application process is complete and accurate. i understand that failure to disclose information about the applicant’s medical, educational or emotional history may affect the school’s admissions decision and that the school reserves the right to reverse an admissions decision, even after acceptance and enrollment, if such information has been withheld from the school. i further understand acceptance is based on approval of credit and that i may be subject to a credit check by fairmont private schools, inc. print parent/Guardian’s name: _______________________________________________________________________________ parent/Guardian’s signature: _______________________________________________ date: ______/_______/__________

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Fairmont International Education
TO THe ApplicAnT:
(please type or print clearly)

math teacher reFerence

student name __________________________________________ date of Birth _________________

male

female

school you now attend _______________________________________________________________________________________ candidate for the academic year beginning _______________ Grade: 7 8 9 10 11

TO THe TeAcHer:
This student is applying for admissions to fairmont international education program. in providing you with this form, the student and his/her parents have authorized release of all requested information, including disciplinary actions. A full report is essential if the student is to be given fair consideration in our selection process. please bear in mind that admission is competitive and that the Admissions committee depends on your candid evaluation in making its decision. This form is confidential. please return directly to fairmont international education program. course title and level (reg./Honors/Ap/iB) How long Have you Know the candidate? Textbook or other materials used? course topics covered? current grade (%)

evAluATiOn:
AcAdemic ATTriBuTes Academic potential Academic Achievement Willingness to participate in class Ability to Work independently Organizational Ability creativity/imagination study Habits study skills motivation reading/Writing skills www.fairmontschools.com | 5 Truly Outstanding Above Average Average Below Average poor no Basis for Judgment

Fairmont International Education
evAluATiOn (cOnT’d):
persOnAl ATTriBuTes Honesty/integrity self-confidence concern for Others emotional maturity respect Accorded by staff/faculty communication with Adults peer compatibility Truly Outstanding

math teacher reFerence

Above Average

Average

Below Average

poor

no Basis for Judgment

What are the first words that come to mind when describing this student?

________________________________

________________________________

_____________________________

please provide any additional insight about the applicant that will guide the Admissions committee:

______________________________________________________________________________________________________ _____________________________________________________________________________________________________

TeAcHer recOmmendATiOn:
Truly Outstanding Honesty/integrity self-confidence concern for Others strong Average poor

print Teacher’s name: _______________________________________________ Title ________________________________ school Address: ____________________________________________________ school phone ________________________ Teacher’s signature: ________________________________________________ date: ________/_________/____________

Thank you for filling out this recommendation. please mail this completed form to:
fairmont international education Office of Admissions 2200 sequoia Avenue | Anaheim, cA 92801 714.999.5055 www.fairmontschools.com 6 | www.fairmontschools.com

Fairmont International Education
TO THe ApplicAnT:
(please type or print clearly)

english teacher reFerence

student name __________________________________________ date of Birth _________________

male

female

school you now attend _______________________________________________________________________________________ candidate for the academic year beginning _______________ Grade: 7 8 9 10 11

TO THe TeAcHer:
This student is applying for admissions to fairmont international education program. in providing you with this form, the student and his/her parents have authorized release of all requested information, including disciplinary actions. A full report is essential if the student is to be given fair consideration in our selection process. please bear in mind that admission is competitive and that the Admissions committee depends on your candid evaluation in making its decision. This form is confidential. please return directly to fairmont international education program. course title and level (reg./Honors/Ap/iB) How long Have you Know the candidate? Textbook or other materials used? course topics covered? current grade (%)

evAluATiOn:
AcAdemic ATTriBuTes Academic potential Academic Achievement Willingness to participate in class Ability to Work independently Organizational Ability creativity/imagination study Habits study skills motivation reading/Writing skills www.fairmontschools.com | 7 Truly Outstanding Above Average Average Below Average poor no Basis for Judgment

Fairmont International Education
evAluATiOn (cOnT’d):
persOnAl ATTriBuTes Honesty/integrity self-confidence concern for Others emotional maturity respect Accorded by staff/faculty communication with Adults peer compatibility Truly Outstanding

english teacher reFerence

Above Average

Average

Below Average

poor

no Basis for Judgment

What are the first words that come to mind when describing this student?

________________________________

________________________________

_____________________________

please provide any additional insight about the applicant that will guide the Admissions committee:

______________________________________________________________________________________________________ _____________________________________________________________________________________________________

TeAcHer recOmmendATiOn:
Truly Outstanding Honesty/integrity self-confidence concern for Others strong Average poor

print Teacher’s name: _______________________________________________ Title ________________________________ school Address: ____________________________________________________ school phone ________________________ Teacher’s signature: ________________________________________________ date: ________/_________/____________

Thank you for filling out this recommendation. please mail this completed form to:
fairmont international education Office of Admissions 2200 sequoia Avenue | Anaheim, cA 92801 714.999.5055 www.fairmontschools.com 8 | www.fairmontschools.com

GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY

Grades K-12
INSTRUCTIONS Use this guide as a quick reference to help you determine whether children seeking admission to your school meet California’s school immunization requirements. For the actual laws, see Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 8, Sections 6000-6075. If you have any questions, call the Immunization Coordinator at your local health department. To enter into public and private elementary and secondary schools (grades kindergarten through 12), children under age 18 years must have immunizations. IMMUNIZATION REQUIREMENTS

VACCINE
Polio

REQUIRED DOSES
4 doses at any age, but... 3 doses meet requirement for ages 4–6 years if at least one was given on or after the 4th birthday1; 3 doses meet requirement for ages 7–17 years if at least one was given on or after the 2nd birthday.1 Age 6 years and under: DTP, DTaP or any combination of DTP or DTaP with DT (diphtheria and tetanus) 5 doses at any age, but... 4 doses meet requirements for ages 4–6 years if at least one was on or after the 4th birthday.1 Age 7 years and older: Tdap, Td, or DTP, DTaP or any combination of these 4 doses at any age, but...3 doses meet requirement for ages 7–17 years if at least one was on or after the 2nd birthday.1 If last dose was given before the 2nd birthday, one more (Tdap) dose is required.

Diphtheria, Tetanus, and Pertussis

Measles, Mumps, Rubella (MMR)

Kindergarten: 2 doses2 both on or after 1st birthday.1 7th grade: 2 doses2 both on or after 1st birthday.1 Grades 1–6 and 8–12: 1 dose on or after 1st birthday.1

Hepatitis B3 Varicella Tdap Booster (Tetanus, reduced diphtheria, and pertussis)
1 2

Kindergarten: 3 doses at any age 1 dose for children under 13 years.4, 6 7th grade: 1 dose on or after 7th birthday. 5

3 4 5 6

Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization requirement. Two doses of measles-containing vaccine required. One dose of mumps (Kindergarten only) and rubella-containing vaccine required. No longer required for 7th grade beginning July 1, 2011. Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement. Tdap, DTaP, or DTP given on or after 7th birthday will meet the requirement. Td does not meet the requirement. A 2 dose varicella requirement for ages 13-17 years applies to transfer students who were not admitted to California school before July 1, 2001.

EXEMPTIONS

The law allows parents/guardians to choose an exemption from immunization requirements based on their personal beliefs or medical exemptions. For children with medical exemptions, the physician’s written statement should be submitted. Schools should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs. Refer pupils who do not meet these State requirements to their physician or local health department. Give families a written notice indicating which doses are lacking. Children who lack one or more required vaccine doses that are not currently due may be admitted on condition that they receive the remaining doses when due. Refer to Title 17, CCR Section 6035 for more information.
California Department of Public Health ? Immunization Branch ? ShotsForSchool.org

NOT MEETING REQUIREMENTS CONDITIONAL ADMISSIONS
IMM-231 (12/11)

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letter oF suPPort
The us department of Justice (immigration and naturalization service) requires an affidavit of support be filed for international students. The following letter is a sample that meets government approval. The letter must be notarized and must be officially stamped to be valid.

date ___\___\______

To Whom it may concern:

i, _____________________________ (parent’s name), will be financially responsible for all expenses (tuition, transportation, living, food, home stay, etc.) while my child, _______________________________ (student’s name), _______________________________ (student’s date of birth),
month date year

is studying in the united states.

All united states laws and guidelines will be upheld and followed.

Thank you for your attention in these matters.

sincerely,

_______________________________ (Parent’s Signature) _______________________________ (Parents’s Name)

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Tuition Refund Plan

Fairmont international education

fAirmOnT’s TuiTiOn refund plAn
investing in your child’s education is an important commitment that you make in advance of the beginning of the academic year. Occasionally, this commitment must be broken for unforeseen circumstances such as a job transfer or prolonged illness. fairmont makes commitments for operational expenses (salaries, books, supplies, insurance, etc.) prior to the start of each school year. When a student leaves fairmont, for whatever reason, there is a significant impact on our ability to meet those obligations. All fairmont families are automatically enrolled in the Tuition refund plan underwritten by A.W.G. dewar insurance Agency. The plan pays benefits (subject to its terms, conditions and limitations) to the school should your child withdraw before the end of the school year. for more information about your coverage under the plan, please see the Tuition refund plan leaflet included in your admissions or re-enrollment materials or available from your campus Admissions director.

filinG A clAim:
1. submit insurance claim form (available from your campus Admissions director) on or before the time you withdraw your child. return the original form--photocopies, scans or faxes are not acceptable. fairmont’s Accounting department officially files your claim with A.W.G. dewar. The insurance company remits payment to fairmont within 30-60 days. fairmont submits your final statement in one of two ways: 1) issuing a check for the credit on your account or 2) issuing a bill for the balance on your account. if a balance remains on your account, you have 7 days to arrange for payment or fairmont may pursue further collections efforts.

2. 3.

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