International Student Program

Date of Application:


APPLICATION PACKAGE CHECKLIST A complete application package includes the following:  Completed Student Application Form  Completed Homestay Placement Form (if applicable)  Original or certified copies of transcripts or school records from the previous 2 years of schooling (translated into English) - please include grade 9 transcript (if applicable) and if you plan to graduate  A letter of recommendation from the principal/director or other school official of your current school  A current photograph (preferably 3 passport-sized photographs)  A copy of SLEP or other English language test (optional)  Application fee of $200 Canadian payable to the Pembina Trails School Division

Mail completed application package to: The Director, International Student Program Pembina Trails School Division 181 Henlow Bay, Winnipeg, MB R3Y 1M7 Canada



Name (as on passport): Date of Birth:




 Male


 Female


Permanent Address:

Street Address





Country of Birth:

First Language:

Second Language:


Postal/Zip Code


Father’s Name: Cell Phone:

Date of Birth: Surname




Business Phone:

Email: Mother’s Name: Cell Phone: Email:

Date of Birth: Surname




Business Phone:



If you are currently registered in school, please complete the following: Name of School: Address:

Street Address




Month school begins:

Number of years in current school:


Last completed grade:


Special Interests:  Math/Science  Literature  Music/Drama  Dance

Postal/Zip Code

When completed:



 Computers  Visual Arts  Other (specify)

Do you play a musical instrument?  Yes If yes, please indicate the instrument(s).

 Sports

 No

Note: Pembina Trails School Division reserves the right to determine the grade/school placement. Preferred grade in Pembina Trails:

 No preference

Preferred school in Pembina Trails:

 No preference

Anticipated start date: I am applying for:

Anticipated end date:

 First semester only  Other (specify)

 Second semester only

 Full school year

Do you have or have you had any medical, psychiatric or emotional conditions that could impact your ability to be successful in participating in an International Student Program?  Yes  No If yes, explain. D.


Do you require a homestay placement?

 Yes

 No

If yes, please complete our Homestay Placement Form. If no, provide the name and address of the person you will be living with while in Winnipeg. Name: Date of Birth:

Relationship: Surname First Middle

Citizenship: (Month/Day/Year)


Home Phone: Business Phone:

Street Address



Email: Fax:

Note: Please visit our website at: to ensure that this person meets the Pembina Trails School Division’s criteria for non-homestay student.



Students do not need a minumum level of English competency to participate in our program. However, it is important that we have a clear understanding of your English language level to place you in the appropriate classes. Please choose () the box that best describes your abilities in English.  No English:

No knowledge of English.

 Beginner:

Able to use some greetings, short sentences but unable to carry on a conversation. Very limited vocabulary.

 Intermediate:

Able to order meals in a restaurant, ask simple directions and read a little. Able to understand some spoken English. Reluctant to speak English.

 Upper-Intermediate:

Able to understand most uncomplicated radio/TV programs. Able to read a little. Comfortable speaking in a social environment (simple topics). Make many mistakes and do not have the vocabulary to express more complicated messages clearly.

 Advanced:

Able to understand and use English in most situations. Comfortable speaking English and have little difficulty expressing thoughts. Make few errors.

 Native Speaker:

Speak and understand English like a native speaker.

Have you spent time in an English-speaking environment? If yes, explain (where, why, when and for how long?).


 Yes

 No


Please indicate your learning objectives for studying in the Pembina Trails School Division. Please choose () all of the learning objectives from the list below that apply to you.  Improve English skills. I do not wish to obtain credit for my courses (audit courses only).  Improve my English and take specific courses for credit. Please complete Course Selection section G on page 4 of this application.  Improve my English and take courses assigned to me by the school.  Graduate with a Manitoba High School Diploma. If yes, please include your grade 9 transcript.



FOR GRADES 10, 11 AND 12 APPLICANTS ONLY. Below are categories offered at each high school. Please choose () and rank 6 from the list below (#1 will represent your top choice) so that we may know your interests and requirements. You will choose your specific courses from a more extensive list before classes begin. Please circle all courses that you need validated by your school back home. Please note that schools do their best to meet your requests but are not able to guarantee all of your choices.  English (regular program)  English as a Second Language (ESL)  Mathematics  General Science  Biology (grades 11 and 12)  Physics (grades 11 and 12)  Chemistry (grades 11 and 12)  Computer Science  World Issues (grade 12)  Art  Physical Education  Social Studies  American History (grade 10)  Canadian History (grade 11)  Georgraphy (grades 10 and 12)

 Choir  Band  Accounting (grades 11 and 12)  Drama  Dance  Economics (grade 12)  Religion (grades 11 and 12)  Home Economics/Family Studies  Spanish Language  French Language  Other:

I learned about the Pembina Trails School Division International Program from: Please choose () one of the following.  Friend/Relative  Internet  Advertisement  Agent H.

 Attending a Fair  E-Newsletter

 Government Office  Other:


I understand that a successful experience in the International Student Program of the Pembina Trails School Division depends upon regular class attendance, completion of all homework and assignments and participation in all activities offered by the program. I acknowledge that the International Student Program of the Pembina Trails School Division reserves the right to dismiss students and return them home, at their expense, without tuition refund for violating any of the rules set out by the program (see Refund Policy at I understand that serious breaches of program rules include, but are not limited to: • Driving a motor vehicle • Using alcohol or illegal drugs • Inappropriate use of social media (e.g. Facebook) • Breaking homestay rules • Engaging in any illegal activities • Unauthorized travel outside of Winnipeg • Not maintaining a minimum of 4 courses per semester • Holding a paying job • Violating the rules set out in our Standard of Behaviour ( I undertake to abide by the program regulations and to cooperate with administrators, teachers and students in the Pembina Trails School Division. Student Signature




The signature below acknowledges agreement with the following: • The Pembina Trails School Division can, at its discretion, dismiss my child and return him/her home at my expense without tuition refund for (i) providing false and/or inaccurate information on this Student Application Form and/or (ii) violating any of the rules (see above) set out by the International Student Program. • I have read and understand the Refund Policy ( and the document entitled: Standard of Behaviour ( • If my child’s educational or homestay needs are greater or become greater than disclosed in the application process,the Pembina Trails School Division has the authority to charge for extra support, if available or at its discretion, to send my child home at my expense. • My child has no history of criminal behaviour. • The Pembina Trails School Division is not legally liable should my child be injured while in Canada. • Any litigation involving the Pembina Trails School Division will be conducted in, and according to the laws of the Province of Manitoba. • My child has my permission to travel with their homestay family within the Province of Manitoba and/or N orthern Ontario and/or to participate on any day trip within the Province of Manitoba that is arranged by the Pembina Trails School Division. • The Pembina Trails School Division has my permission to use photographs and/or videos of my child and/or artwork and/or written work produced by my child in any promotional material and/or professional media for their International Student Program.

Parent Signature

International Student Program


Homestay Student Application Form

Revised 09.09.2016/CK