CULTURAL HOMESTAY INTERNATION (AL | 7 Ep AVENUE, SAN Raraet, CA 94901 82_Ewalt CA QCA OR Work & TRAVEL Fit and idl ‘peed in Passport) BNR Jems - ‘ate tinh DosonberO. 1556 7 arto Dominga Poe af bi (country Oommen REPU » Domncan Repabie rae i rvremanet residence DOMAIN RepLBIC Fesmnas aba Avon 2 et #192 ia Mela inact ane: Leena vio Nunez Cipran ave you ever ben on a work vel program VES LINO YES. what was the name ofthe program? Sumer work and vel ric Yoon 202 of higher ming: O8M Usversty WS CAPITALS) to be completed by school ‘Leon that Mr/Ms, BON Seems NEVE SGUNO Ts rogstrad in our instution as flim stden forthe academe year (20227 wan summer vacation between (es, 25/hun 2016 and.) 08/82/2027 ng 8/10 ‘Name Mil Miimie Suen Feliz Title Manager Phone tax 828-902-7060 E-Mail nyani@outookeom Ea Seton Seal PROOF OF SUFFICIENT FUNDS,|) Paisiation tthe Ct aientation tng matory 2 Include inthe eriemtaton meting information bout ving and working in the US Partin’ Signature 2 Date: ACKNOWLEDGEMENT OF CULTURAL PROGRAM undead a apripntin CS USA Wo & Tl Program. my can prima asi a Betet Understanding ofthe customs and exe inthe US. ough eration wth US. etaens while sharing my own clare wit ‘Amesians that meet though tae! and work oportnities, ACKNOWLEDGEMENT OF PROGRAM RULES, TERMS AND CONDITIONS ER CHT’ USA Work & Travel offers cher a Sel Placed option in which the pticipats ind their wn job ora Job Assisted option in which CHT assists wth the selection of ob placement. Far bth eptions the job ae must be veted an apaved by CH Papa requres CHI approval before begining primary or cay employment 2) The participants required oul hs or er ncton to parcpate nthe cual aspect ofthe Summer Work & Travel 3) USA Work & Travel paisians ae required w havea jo fer ssa prior to aving inthe US. The prtiipan andthe US employer are requited 1 siti jo offer bore te Ds ‘eng eudeines and vegulton 4) The partsipatis solely responsible or fllowng al housing contact pistne andi financially responsibe for ay housing and transportation guidance as appropiate Onl in some instances do employers provi hourng, 5) The paicipant is equired to complete the baie USA Work & Tavs application and sunt proof of active stent enolimen 2 Wella document proof of suficent funds (minimum of USDSI.900 in ode for the pipnt Ww denortone sin | supplement and access fands beyond Work & Travel Program employment, ©) The Work and Tan program must adhere to the dite requirements nounced by cach counts Fass and Dos 7)-The USA Work & Travel Program participant is responsible fr validation is her tvs ates tol an ahe oad ‘quired 0 report to CH, the sponsor agers within 3 days of unival othe US Failure tadhere we tic es sed ech {aacelaton ofthe paicipat's Work & Travel Program, The paicpant i reguied fo report all shes thong wae ‘The Self-Paced and Parner Assisted participants re eau to report to CH the in ‘SclPlaed Jab Ofer for CHI veting and approval Bore aeceping the o> 8) The Work Travel Program is subject to termination andor eas completion by the spursor: Reasons fr tesminaton a fel completion include, but ate mot mite ‘olation af DoS andor sponsor rules as oid in Work & Travel Student Handbook: ‘tiie activity, volition of State andor Pera ls, failure wo respond to CHI communication request on imc ass failure to fulfil the requirements of participation inthe cultural aspect of Summer Work & Travel Progan ®) Ahough feral program repaations sat paricipars crm he held na jb gaa he i CHa arisipants to communicate etl with Bah thir mploper AND Cll to give ase we none nee they plan eave tht jab placement and ther eson lor avi. Should the pacipan sree this action wll he considered vilation ofthe program sponsor's (CHI) ules andy stats, Papas must consult with CH befor taking any acto olan tears 2019s sued, CHI wl only approve placements tha met DOS jo to change thee jab and provide ane Participants Signature 52 sss Date:ANE + tntales potions that rut partcpons opr + Indbmestic help positions ia peivate mes fe child carer cane pa {As peda cling char divers et operan pe + AS operas or divers of vehicles or vsucs for which ves liens ar eure eds Of whether they any p + npn rate i cata nls ptt ota + Inany postion nthe alt entertain nds (cling bu ind ojos wih acon servis ck sors nd tp chats + Nis ein wok os ht il edo tsen 100 pan 60am + Inpostons dled hazards to yuh bythe cea of ator a Spo 29 CT pt 7 + Instat equi sane pal ont the opie andar to te Centers or Disease Cn Freventons Univeral Bod and Boy lal Psat pcs hoy pee, oi mnsage mance + fpstons ta are susan corms det ara ta prin wl Be pad min wae conceit dr nde ana Un pestns vied in gaming an ning thle det patton in wagering ano sting Imposition which there aera ea (cmp comel itr, ines; + Impostnsin th Non American idryClsieaon Syste [NATE ihe following esupational sets: Agric Fore Fishing Hing Ming. Quai and Oi and Gas Fat, Constacon a Manicuring In gsiton tt equ haere Prog particu arnt lone work sting agers nr as independent ons al Puts ad Summer Camps In postions with Laundey Services, In postions with Movers Moning Services + In Janitorial postions a tine a NAICS. 561720 inching business ering houskespin nd aid service + Inpostions in Balad or remote locations, excting Nat Is 1) The cate program fe balance must be pai in ll and he job accptance Iter completed BEFORE CHI can issue the DS fom, 2) The DS-2019 fom is NOT a vis. The prtcipant must take the DS-2019 form and apply forthe - visa athe nearest US Consulate inthe parcinan's hme county. Without a curren vias tape in th asspor: paripaan inthe wees 3) The J visa allows the participant to enter and legally workin the U.S. for up to 4 months maximum, 4) An onal 30-day travel peri aval upon succesful completion othe program, ding eh the aipant may wal around the 50 sates an ich District of Coluniia 5) Include inthe program fees compulsory comprehensive insurance fr she duration of the program as nice on the Bs-2019 fem. The US. goverment required that al paricipans hae insurance coverage dung the ocean paral eos optional 50-day tael period can be purchased fr an addtional ee through CHIE Paricpan, we fake insurance cover any adiional ines a fous. 6) The paisipant agrees to begin work 0 carl tan the dat indicated om hier BS.2019 form AND aetes to terminate we ‘latins in th US. no later than the dat nda om his her DS-2019 frm, 2) her apy fr insurance under the Glotl Secuive LLC plc, the petadconsiing with the stat and end 'DS-2019 form. understand the tems and conitons ofthe isan planICANCELLATION POLICY 1) Cancellations received Between the tine of application submission and issuance ofthe DS. ancellaton fee Canelatins recived ale stanee ofthe DS-2019 farm are subject to a partial ffund of the program f= pe ‘eect ofthe unvsed DS.2019 form, Please refer tothe regulations asst forth by your azeney in your home country 2) Incase of ws dena, the unused DS-2019 for must he etn to CHI wth peo of denial aler which pata rend wil be Issued, Please refer othe reaulatons a set forth by your agen i Sour home cont 3) The puticipant snot eligi fora refund once he she has entered the U.S. This includes changing of jobs. termination of employment and orearly departure trom the US. back tothe home county SON 1) Failure to notify CT of any changes im employment or residence may test in puting the priipan’s program stat at 2) The participant understands and agrees to mani a valid emai account athe US. daring the program asa means to omnia with CHL 3) Failure to request CHT authorization before begining any typeof employment may jeopardize the participant's pram status 4) I ascordanes to DoS repulatons CHT is requied to maintain monthly contact with cach USA Work & Travel participant The participant agrees to respon to any e-mail eammaniiton set rom CHE including bu pt Fimited to monthly evaluation requests and request fo report fulfilment of the cultural aspects ofthe USA Work & Travel program. Failare to respon to CHE communication may jepardize the patiipan’s rogram status, Te In-consderation of ing accepted By CHES USA Work & Travel Pro harmless Cura Homestay Intemational, its overseas Pater organizations andor principals therot fom any an al bili etaims or demands for personal injury sikness or death aswell as property damage and expenses of any nature whatsoever which may be incurred by the undersigned that may occur while participating i the USA Work & Travel program. [understand that by signing this Release fll and completly wave and clings all ims I may have against Cultural Homesty International, ‘ts cmplayces and its overseas Parner onanizations thera and release them from an Habit they may eens have toward ime, whether known tome or nt. U authorize all mica gross to rslease my personal medical information i the event of an accident medical treatment or hospitalization, to CHI a my visa sponsor authorize CHE to use my photograph ins promotional tates forthe USA Work and Travel progam. sam. Verchy release, forever discharge and agree to hold Paricipa’s Signature 5° ue Date ne Inthe event of any dispute between the putes conceming the performance, enforcement ot interpretation of this Apreen iste shall be determined by binding arbitration befor the American Arbon Association ot Facial Aico and Mesto Services in San Rafal, Masia Counts, Califia, USA, upon the petition of ether ary, The dsvsion of the arbitrator shal be fil and binding and may be enforced i any court of competent jurisdiction othe petition of ether party, The usin ae tha Marin County, Califomia, USA isa far and reasonable venue for esluion ot any such depute at bint to jarsiction of te Cours ofthe State of California because, among ther esans ths Agreement ss neti in lage pt Califia. and CII 5 domiciled in Marin Count; California MENT OF AND CONDITIONS Thave sad the rules, conditions and elsbiy requirements of CHI's USA Work & Travel program and the Participant Hanook and agree to abide by them, agree to comply with my US. employers rales and policies, ncuns utr ine Such as personal grooming snd drug testing. understand tat al employment arrangements made by mv. with the help of CHL tomy anival are subject to change or cancellation, tn the event of relocation, | understand that wage positon type and local be diferent and tat paipation in the program requires my lexibliy i evaluating the Work opportunities offered by CHL derstand that work hours may vary depending on weather contons ffecting te evel of business aseupaney of the host ep "agree to report to my pr-assigned job and fll my work dates a agreed onthe Job Offer anor on w aiionlauteencns alse understand that CHI wil follow US, Department of State guidlines provid to Sponsors when determining aos ration or reporting out-fsttus prints the Federal Government By participating im CH= USA Work & Travel ny oc te governed by US. atonal and local aus. I Lam vole in any egal consequence, lam responsible fr any newest le tion a ell ary and al expenses incurred. will no engage in payment wo US, host emplasers, sang agencies or a ary to provide or faciitte a Job Ofer and twill not subi a invalidiraadulent ob ofr with my application {ure dela that all aplication information submited true. understan that any fake declaration on my prt or submission of nace tdocurens may result in forfeiture of my place an this program with to entiement to any refund Paricipaor’s Signature Due