ARE YOU READY TO APPLY FOR AN EXCHANGE? YES I NEED MORE INFORMATION Experiences Canada IN PERSON ONLINE APPLICATION FORM Experience Canada's vision is to promote an environment in which all Canadians take full advantage of dynamic cultural experiences, celebrate our history and heritage, and participate in building creative communities. 1. NOTE Funding an exchange is subject to the applicant entering into a participation Agreement* with Experiences Canada. Travel costs for eligible participants are paid by the Government of Canada through Experiences Canada youth exchanges program. Participating groups are responsible for hosting arrangements, local transportation and costs of activities. Successful applicants are required to pay $250 registration fee per person after returning the signed Agreement. All youth participants must be new to the exchange program. Returning youth may participate at their own costs. To ensure the safety and the security of all participants, all volunteers and adults over the age of 18 living in the host family household are required to provide a clear police record and vulnerable sector checks. 1. Group Identification (Page 1 of 7) Group Information Type of GroupSchoolCommunity Organization Name of School/Organization IN FULL (no acronym) Street Address City Province/TerritoryPlease select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Postal Code (in A1A 1A1 format) Telephone Number Website Address Enter School Board name IN FULL (no acronym) Do you have Board Approval?YesNo Group Organizer Information SalutationMr.Mrs.M.MmeMs. First Name Last Name Home Address Street City Province/TerritoryPlease select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Postal Code (in A1A 1A1 format) Mobile Number (Used for travel updates and emergencies Telephone Number (Home) Email In which language do you want to correspond with us? EnglishFrench School Principal or Club President Note: For safety reasons, the organizer named in Section 3 and the Principal/President named in Section 4 cannot be the same person. The Principal/President must have the authority to legally bind and sign the Agreement of participation on behalf of the school, school board or Club. SalutationMr.Mrs.M.MmeMs. Title or Role Principal First Name Principal Last Name Daytime Telephone Number Email 2. Group Profile (Page 2 of 7) NOTE: Experiences Canada’s chaperone ratio is 1 / 10:Groups of 10 to 20 youth: 2 subsidized chaperonesGroups of 21 to 30 youth: 3 subsidized chaperones a) Estimated Number of Participants (minimum 8 youth and 2 adults): Female Youth Please ensure the minimum group size is no smaller than 8 youth x Male Youth Please ensure the minimum group size is no smaller than 8 youth x Female Chaperones Male Chaperones b) Please indicate your group size flexibility (minimum 8 youth and 2 adults): Flexible Group Size - Minimum Please ensure the minimum group size is no smaller than 8 youth x Flexible Group Size - Maximum Please ensure the maximum group size is no bigger than 45 youth x c) Please indicate your age range of Youth: Youth Age Range - Minimum (12) Please ensure the minimum age is no younger than 12 x Youth Age Range - Maximum (17) Please ensure that maximum age is no older then 17 x d) Grade level(s) of the participants6789101112 e) Mother Tongue of ParticipantsEnglishFrenchOther Other Mother Tongue 3. Group Description (Page 3 of 7) We encourage the participation of youth who have traditionally been under-represented in exchanges. Please indicate if your group includes youth who fall within the following groupings: (please see Definitions on page 7 of the Application Guide) (1) Youth with Special Needs and/or Disabilities? A person with a long-term physical condition, mental condition, or health problem, who is limited with respect to functions in the home, in school or other activities (e.g. leisure time activities)YesNo If yes, approximately how many total? (2) Youth from Low-Income Households? A person who lives in a household earning less than the Low Income Cutoff as defined by Statistics CanadaYesNo If yes, approximately how many total? (3) Visible minority youth? An individual, other than an Indigenous person, who is non-Caucasian in race or non-white in colourYesNo If yes, approximately how many total? (4) Indigenous youth? A member of a First Nation, a Métis or an InuitYesNo If yes, approximately how many total? (5) Youth from Rural or Isolated Areas? A person who lives in a community with a population less than 10,000YesNo If yes, approximately how many total? 4. Exchange Description (Page 4 of 7) Educational focus Please select your PRIMARY and SECONDARY educational focus of your exchange.If an application matching with your primary focus is not available, we will look for an application matching with your secondary educational focus. a) Please select a primary theme from this listPlease select... Human Rights Immigration and Diversity Indigenous - Indigenous (intra cultural) Indigenous - Non Indigenous (inter cultural) Official Languages & Cultures - English Second Language - (ESL) Official Languages & Cultures - French Second Language - (FSL) Anti-Bullying Theme - Band Theme - Choir Theme - Community Involvement Theme - Cultural Enrichment & Traditions Theme - Dance & Dramatic Arts Theme - Environment Theme - Geography Theme - History and Heritage Theme - Leadership Theme - Religious Groups Theme - Science Theme - Sports Other Primary theme Other b) Please select secondary theme from the list:Please select... Human Rights Immigration and Diversity Indigenous - Indigenous (intra cultural) Indigenous - Non Indigenous (inter cultural) Official Languages & Cultures - English Second Language - (ESL) Official Languages & Cultures - French Second Language - (FSL) Anti-Bullying Theme - Band Theme - Choir Theme - Community Involvement Theme - Cultural Enrichment & Traditions Theme - Dance & Dramatic Arts Theme - Environment Theme - Geography Theme - History and Heritage Theme - Leadership Theme - Religious Groups Theme - Science Theme - Sports Other Secondary theme Other Linguistic focus c) Are you applying for a bilingual exchange? YesNo d) If an application matching with your bilingual focus is not available, would you like to be considered for an exchange with a group whose maternal language is the same as yours?YesNo Official Minority Community (OMLC) Canada’s official languages are English and French. Official language minority communities (OLMCs) are groups of people whose maternal or chosen official language is not the majority language in their province or– in other words, Anglophones in Quebec and Francophones outside of Quebec. For the purposes of its programs, Experiences Canada defines OLMC groups and organizations as those who self-identify as belonging to one of these groups. e) Is your group an Official Language Minority Community (OMLC)?YesNo f) If yes, would you like to be twinned with another Official Minority Language Community group?YesNo g) - If yes. If another Official Language Minority Community application is not available, would you consider to be twinned with a non-OMLC application?YesNo 5. Specific Requests (Optional) (Page 5 of 7) Are you requesting a specific twin?YesNo Twin Group Information Name of Twin School/Group Requested Twin Group Street Address Twin Group City Twin Group Province/TerritoryPlease select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Twin Group Postal Code Twin Group Telephone Number Twin Group Organizer's First Name Twin Group Organizer's Last Name Twin Group Organizer's Telephone Number Twin Group Organizer's Email Address How Did You Hear About Exchange Canada?Please select... Colleague who took a group on an exchange Previous Participation in an exchange Phone call from Experiences Canada Experiences Canada Professional Development Conference Conference (non-Experiences Canada) Web search Social Media Experiences Canada Newsletter Email Link from another web site Publication ad Radio Other 6. Exchange Period (Page 6 of 7) Exchange period Please select your preferred exchange period:SCHOOL YEAR 23/24SUMMER 24/25SCHOOL YEAR 24/25SUMMER 25/26 Please indicate your preferred Travel and Hosting periods Preferred Travel YearPlease select... 2019 2020 2021 2022 2023 2024 2025 2026 2027 Preferred Travel MonthPlease select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Preferred Hosting YearPlease select... 2019 2020 2021 2022 2023 2024 2025 2026 2027 Preferred Hosting MonthPlease select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 7. Agreements (Page 7of 7) Due to a high demand for exchanges and limited funding, not all applications will result in an approved exchange. Experiences Canada tracks all groups’ history to ensure that everyone has equal access to the program. For more detailed information, please review Experiences Canada:Privacy policyFAQParticipation AgreementApplication Guide IMPORTANT! I have read the Application Guide and Participation Agreement and confirm that my group complies with all the criteria. I understand that my application will not be complete and will not be considered until the following 2 items are received by Experiences Canada:Yes $250 Group membership feeAcknowledgement form Payment can be made by: Interact E-transfer to fees@experiencescanada.ca. Please indicate in the memo line the name of your group and project number. Password is not required. Do not add a password.Visa or MasterCard by calling Experiences Canada at 1-800-387-3832Cheque payable to Experiences Canada. Please clearly indicate on your cheque the name of your school or association and the Group Organizer’s name, and mail to Experiences Canada at 202-2148 Carling Ave., Ottawa, ON K2A 1H1 Contact Information