ApplicationPackage2015SCAS25thAnniversaryStudentDelegationAshikagaStudentDelegationTravelDates:June1929,2015
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
Pleasenotethatsomeapplicationpages(*)mustbenotarized
Completed,signed,3pageApplication
SignedcopyofBasicPoliciesforExchangeStudents Medical
ReportForm
EmergencyInformationForms* BoththeSCASandJapaneseForm
WaiverofResponsibility
Forms*BoththeSCASand
JapaneseFormArecentphotograph
Depositcheckmadepayableto"SCAS"or
"SisterCitiesofSpringfield"
(Willnotbecasheduntilapplicantisacceptedfortrip)
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
Pleasenotethatsomeapplicationpages(*)mustbenotarized
PleasesubmitthefollowingtobeconsideredforapositionintheSCASdelegationtoAshikaga: Completed,signedapplication(pages13) SignedcopyofBasicPoliciesforExchangeStudents(page4) MedicalReportForm(page5) EmergencyInformationForms*(SCASandJapaneseforms)(pages67) WaiverofResponsibility*(SCASandJapaneseforms)(pages89) Authorization(page10) Arecentphotograph Depositof$200(yourcheckwillNOTbecasheduntilstudentisacceptedandwillbe
returnedifthestudentisnotaccepted).Makecheckpayableto:
SisterCitiesAssociationofSpringfieldorSCASCompletetheformsonacomputer(desktoporlaptop)andemailorsubmitthemto:[email protected],2015to:
InitialinterviewswillbescheduledforSaturday,March7,2015.Timeselectionsforinterviewswillbebasedonorderofapplicationsreceived.Please keep this page and copies of all the documents you submit for your own records.
Carol Zerkle SCAS Ashikaga Committee Chair 2015 SCAS 25th Anniversary Student DelegationAshikaga 917 West Lake Shore Drive Springfield, IL 62712
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
APPLICATIONpg.1
Student Delegation Application --> DEADLINE: February 28, 2015 After saving this document with a file name of lastfirst.pdf (e.g. smithjohn.pdf) please complete this form using the free Adobe Acrobat Reader. Be thorough and thoughtful when you complete the form because your answers will help us select students for this delegation. They may also be used to match you with an appropriate host family in Ashikaga.
DelegationApplicant(student)LastName: FirstName: Nickname(ifany): DateofBirth(MM/DD/YY): StreetAddress: City: State: ZipCode: HomePhone: StudentCellPhone: Familyemail: Studentemail: CurrentGrade: School: Graduation(MM/YY)
Parent(s)orLegalGuardian(s)Parent1/Guardian1 Parent2/Guardian2
FullName: FullName: Address: Address: Occupation: Occupation: HomePhone: HomePhone: CellPhone: CellPhone: WorkPhone: WorkPhone:
PeopleinStudentsHousehold
Pleasetellusthenamesandassociatedinformationofeveryonewhocurrentlylivesinthesamehouseasyoudo.Youdonotneedtolistyourselforyourparents/guardians.
FullName(firstnamelastname)
RelationshiptoYou Occupation(ifretired,occupationbeforeretiring) Age
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
APPLICATIONpg.2
Whydoyouwishtoparticipateinthisprogramasastudentdelegate?
AreyoufamiliarwithJapanorwithSpringfieldsSisterCityprogramwithAshikaga? YesNo Ifyes,inwhatway?
HaveyoubeeninvolvedinSpringfieldsSisterCityactivities? YesNo Ifyes,describeyourinvolvement:
ListallyourForeignLanguages(ifany)
Language Howlonghaveyoustudied? Speak? Read?
DoyouhaveaPassport? YesNo Ifyes,whatisthedateofexpiration(MM/DD/YY):
HaveyouevertraveloutsidetheUnitedStates? YesNo Ifyes,whenandwhere:When Where
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
APPLICATIONpg.3
StudentExchangeProgramsHaveyouparticipatedinotherstudentexchangePrograms? YesNo Ifyes,whenandwhere:Year Program/Location Haveyoueverhostedaninternationalpersoninyourhome? YesNo Ifyes,whenandfromwhere:Year Program/CountryofGuest
AllAboutYou
Whatareyourfavoritesubjects?
Whatschoolactivitiesareyouinvolvedin?
Whatcommunityactivitiesareyouinvolvedin?
Howdoyouliketospendyourleisure/recreationaltime?Hobbies?
Whatotherinformationaboutyourselfwouldyouliketosharewithus?
Listtwoteachers,counselors,orprincipalswhoknowyouasreferences:Name WorkTitle School PhoneNumber
Doyouhavemedicalproblemsweshouldbeawareof?YesNoPleaselistallergies,dietaryrequirements,andanymedicationsyoumayneedtotake.
Iwishtobeconsideredforfinancialassistanceandwillprovidefinancialrecordsifacceptedasadelegate.YesNo
SIGNATURES
StudentSignature Date ParentorGuardianSignature Date
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
BASICPOLICIESFOREXCHANGESTUDENTSpg.4
BASICPOLICIESFOREXCHANGESTUDENTSSCHOOL:Studentsareexpectedtoattendschoolregularlyforthreedays,doassignedhomework,andtakeworkseriously.Youareencouragedtoparticipateinschoolactivitiesandtogetmoreacquaintedwithotherstudents.YouwillbeviewedasambassadorsfromourschoolandfromSpringfield.ILLNESS:Intheeventofillness,doasyourhostfamilyadvises.Ifemergencytreatmentisrequiredoryoubecomeseriouslyill,yourhostfamilywilladvisethedelegationchaperones,thelocalcoordinator,and/oryourparents.PASSPORT:Keepyourpassportinasafeplace.Carryitwithyouonlywhenneeded(duringinternationaltravelandwhenyouaregoingtoexchangedollarsortravelerschecksforyen.)DRIVING:Studentsarenotpermittedtodriveanymotorizedvehicle.ThedrivingageinJapanis18.WORK:Youmaynotworkwhileyouareanexchangestudent,althoughyouwillbeexpectedtodoroutinemaintenanceworkatschool.HOMESTAY:Whilestayingwithyourhostfamily,youwillbeexpectedtoparticipateinfamilylife,whichmayincludeperformingroutinehouseholdtasksorchores.Bealerttothefactthatyourhostfamilywillhavefamilyrulesbywhichyouareexpectedtoabideandthatyourhostfamilymayhaveadifferentapproachtoyoungpeoplethandoesyourownfamily.Theywillprobablyconsultyouaboutyourwishes,andyouwillgettogetherwiththeotherdelegates,butdonotexpecttohangoutortotalkonthephoneasyoumightintheUSA.TRAVELORTRIPS:Duringtheexchangeyoumaytravelwithyourhostfamilyorparticipateinotherorganizedtrips(AshikagaCityusuallytakesthestudentstoNikkoNationalForest,whichisinthenearbymountains).Youmaynottravelalonetodistantpoints.Hitchhikingisnotallowed.ALCOHOLANDDRUGS:Thedrinkingofalcoholisnotallowedduringtheexchange.Legaldrinkingageis21inJapan.Drugs,otherthanthemedicinessentbyyourUSAparent/guardiansorprescribedbyyourdoctor,areforbidden.Japanhasa98%convictionratefordrugabuse.RECIPROCITY:TheSisterCitiesAshikagaCommitteeexpectsyourfamilytohostastudentfromAshikagaaspartofyourcontinuingparticipationinandsupportoftheprogram.WORKSHOPS:ParticipationinuptofiveworkshopsonJapanesecultureandAmbassadorshipisrequired.Parents/guardiansareencouragedtoattendallsessionsandarerequiredtobeatthefirstsession.Youwillreceiveaschedulewithyouracceptanceletter.SisterCitiesAssociationofSpringfieldreservestherighttointerviewprospectivestudents,makefinalselectionsordisqualifyaparticipantpriortodepartureorduringthetripfornoncompliancewithanyoftheSCASpolicies.IHAVEREADTHESEPOLICIES.IAGREETOABIDEBYTHEM.IUNDERSTANDTHATMYFAILURETOADHERETOTHESEPOLICIESMAYRESULTINMYBEINGSENTHOMEATANADDITIONALCOSTTOMYFAMILY.StudentSignature: Date:
WEHAVEREADTHESEPOLICIES.WEUNDERSTANDTHATOURCHILDSFAILURETOABIDEBYTHEMWILLRESULTINHIS/HERBEINGSENTHOME.WEUNDERSTANDTHATINSUCHANEVENTWEARERESPONSIBLEFORANYADDITIONALEXPENSESINCURRED.Parent/GuardianSignature Date:
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
MEDICALREPORTFORMpg.5
MEDICALREPORTFORMThisistocertifythat__________________________________hasbeenexaminedbyaphysicianduringthislastyearandisfittotravelandtoparticipateinastudentexchangeprograminAshikaga,Tochigi,Japan.Parent/GuardianSignature Date:
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga
Student Delegation Travel Dates: June 19-29, 2015
EMERGENCYINFORMATIONFORMSCASpg.6
EMERGENCYINFORMATIONFORMSCASIntheeventofinjuryorillnesstoourson/daughterbornon ,weauthorizeJanetK.KenneyandJamesChipman,thechaperones(andifnecessaryalternatechaperone,LillianR.Groesch)ofthestudentdelegationfromSpringfield,ILtoAshikaga,Japan,oranyonetheyauthorize,tosecuretreatment,deemednecessary,includingtheadministrationofananestheticand/orsurgery.
Parent/LegalGuardianSignature DateNotarizedon in ,ILBy Medicinesoranestheticstowhichourchildisallergicare:
Whatmedicalconditions,ifany,doesyourchildhavethataphysicianshouldtakeintoconsiderationintheeventofanemergency?
EMERGENCYCONTACTS,ADDRESSES,ANDPHONENUMBERSThesepeoplewillbecontactedintheeventofanemergency,ifweareunabletoreachparents/guardians:Name: Relationship: Address: City: DayPhone: EveningPhone:
Name: Relationship: Address: City: DayPhone: EveningPhone: Attachphotocopy/scanofbothsidesofinsurancecardInsuranceCompany: PolicyNumber: NameofPersonInsured:
EMERGENCYINFORMATIONFORMJAPANpg.7
EMERGENCYINFORMATIONFORMJapanOnrareoccasions,anemergencyrequiringhospitalizationand/orsurgerydevelops.Sinceminorsmaynot,asarule,beadministeredananestheticorbeoperateduponwithoutconsentoftheparent(s)orguardian(s),werequestthatparent(s)orguardian(s)completethefollowingstatement.Thisisasafeguardtopreventadangerousdelayinthecaseofanyemergencyandintheeventthatweareunabletocontacttheparent(s)orguardian(s).Intheeventofinjuryorillnesstoourson/daughterbornon ,weherebyauthorizeAshikagaBoardofEducationandCityofAshikagatosecuretreatmentdeemednecessary,includingtheadministrationofananestheticandsurgery.
Parent/LegalGuardianSignature DateNotarizedon in ,ILBy
Medicinesoranestheticstowhichourchildisallergicare:
Whatmedicalconditions,ifany,doesyourchildhavethataphysicianshouldtakeintoconsiderationintheeventofanemergency?
EMERGENCYCONTACTS,ADDRESSES,ANDPHONENUMBERSThesepeoplewillbecontactedintheeventofanemergency,ifweareunabletoreachparents/guardians:Name: Relationship: Address: City: DayPhone: EveningPhone:
Name: Relationship: Address: City: DayPhone: EveningPhone:
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga Student Delegation Travel Dates: June 19-29, 2015
WAIVEROFRESPONSIBILITYSCASpg.8
WaiverofResponsibility SisterCitiesAssociationofSpringfield,IllinoisWe, andtheparents/legalguardiansof ,herebyagreetothefollowingbyaffixingoursignaturesbelowonthisdate:WeherebyreleaseJanetK.KenneyandJamesChipman(andifnecessaryalternatechaperone,LillianR.Groesch);theSisterCitiesAssociationofSpringfield,IL,Inc.,itsBoard,andOfficers:theCityofSpringfield;andSisterCitiesInternationalfromanyresponsibilityfortheactionsofourson/daughterduringtheyouthexchangebothintheU.S.andinJapan.Further,weagreetoholdharmlessJanetK.KenneyandJamesChipman(andifnecessaryalternatechaperone,LillianR.Groesch);theSisterCitiesAssociationofSpringfield,IL,Inc.,itsBoardandOfficers:theCityofSpringfield;andSisterCitiesInternationalfromanyliability,responsibility,damages,expenses,claims,lawsuitsorinjurieswhichmayoccurorbegivenrisetoduringhis/herparticipationintheyouthexchange.Wehaveadequatemedicalandaccident,dismembermentandrepatriationinsurancecoverageforourson/daughter.Wehaveverifiedthiscoveragewithouragentanditisvalidoverseas.Weareabletoprovidedocumentationifasked.Weagreetocompletethemedicalform.Additionally,wewillcompleteandreturntheconsentforemergencymedicalattention,shouldtheneedarise,forourson/daughter.Weagreethatourson/daughterwillnotdriveanymotorizedvehiclewhileparticipatinginthisexchange.WeacknowledgethatJanetK.KenneyandJamesChipman,thechaperones,(andifnecessaryalternatechaperone,LillianR.Groesch)andtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbiddenallstudentexchangeparticipantstodrinkalcoholicbeverages,includingbeer,wine,andsake.WeacknowledgethatthechaperonesandtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbiddentheuseofanydrugsbytheparticipant,saveforthoseprescribedbyaphysician.
Parent/LegalGuardianSignature Date
Parent/LegalGuardianSignature Date
Notarizedon in ,IL
By
WAIVEROFRESPONSIBILITYJAPANpg.9
WaiverofResponsibility JapanWe, andtheparents/legalguardiansof ,herebyagreetothefollowingbyaffixingoursignaturesbelowonthisdate:WeherebyreleaseMr.HiroshiTakagi,SuperintendentofAshikagaBoardofEducation,andCityofAshikagafromanyresponsibilityfortheactionsofourson/daughterduringtheyouthexchangeinJapan.Further,weagreetoholdharmlessMr.Takagi,SuperintendentofAshikagaBoardofEducationandCityofAshikagafromanyliability,responsibility,damages,expenses,claims,lawsuits,orinjuriesthatmayoccurorbegivenrisetoduringhis/herparticipationintheyouthexchange.Wehaveadequatemedicalandaccident,dismembermentandrepatriationinsurancecoverageforourson/daughter.Wehaveverifiedthiscoveragewithouragentanditisvalidoverseas.Weareabletoprovidedocumentationifasked.Weagreethatourson/daughterwillnotdriveanymotorizedvehiclewhileparticipatinginthisexchange.WeacknowledgethatJanetK.KenneyandJamesChipman,thechaperones;andtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbiddenallstudentexchangeparticipantstodrinkalcoholicbeverages,includingbeer,wine,andsake.WeacknowledgethatthechaperonesandtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbiddentheuseofanydrugsbytheparticipant,saveforthoseprescribedbyaphysician.
Parent/LegalGuardianSignature Date
Parent/LegalGuardianSignature Date
Notarizedon in ,IL
By
Sister Cities Association of Springfield, Illinois Phone: 217-622-4622Email: [email protected]
2015 SCAS 25th Anniversary Student Delegation Ashikaga Student Delegation Travel Dates: June 19-29, 2015
AUTHORIZATIONpg.10
AUTHORIZATION
IherebygivepermissionfortheSisterCitiesAssociationofSpringfield,Illinois,Inc.(SCAS)tousephotographsofmeoranyofmywrittencomments,writings,andevaluationsaboutmyparticipationinSCASactivities,events,andtrips.SCASmaypublish,noworinthefuture,suchphotographsandwrittenmaterialstopromoteSCASactivities,asSCASdeterminesappropriate.
SCASDelegationMember(PrintFullName) Signature,SCASDelegationMemberIfDelegationMemberislessthan18yearsofage,
Parent,SCASDelegationMember(PrintFullName) Signature,Parent,SCASDelegationMember
Top Related