Anda di halaman 1dari 13

ApplicationPackage

2015SCAS25thAnniversary
StudentDelegationAshikaga
StudentDelegationTravelDates:June1929,2015

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Completed,
signed,3page
Application

Signedcopyof
BasicPolicies
forExchange
Students

Phone: 217-622-4622
Email: scasilinc@aol.com
Student Delegation Travel
Dates: June 19-29, 2015

Medical
Report
Form

Emergency
Information
Forms* Both
theSCASand
JapaneseForm

Depositcheckmade
payableto"SCAS"or
"SisterCitiesof
Springfield"

Arecent
photograph

Waiverof
Responsibility
Forms*Boththe
SCASand
JapaneseForm

(Willnotbecashed
untilapplicantis
acceptedfortrip)

Pleasenotethatsomeapplicationpages(*)mustbenotarized

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Phone: 217-622-4622
Email: scasilinc@aol.com
Student Delegation Travel
Dates: June 19-29, 2015

PleasesubmitthefollowingtobeconsideredforapositionintheSCASdelegationtoAshikaga:
Completed,signedapplication(pages13)
SignedcopyofBasicPoliciesforExchangeStudents(page4)
MedicalReportForm(page5)
EmergencyInformationForms*(SCASandJapaneseforms)(pages67)
WaiverofResponsibility*(SCASandJapaneseforms)(pages89)
Authorization(page10)
Arecentphotograph
Depositof$200(yourcheckwillNOTbecasheduntilstudentisacceptedandwillbe
returnedifthestudentisnotaccepted).
Makecheckpayableto:

SisterCitiesAssociationofSpringfieldorSCAS

Completetheformsonacomputer(desktoporlaptop)andemailorsubmitthemto:
scasilinc@aol.com

AND
SendhardcopiesoftheaboveitemsbyFebruary28,2015to:

Carol Zerkle
SCAS Ashikaga Committee Chair
2015 SCAS 25th Anniversary
Student DelegationAshikaga
917 West Lake Shore Drive
Springfield, IL 62712

InitialinterviewswillbescheduledforSaturday,March7,2015.Timeselectionsforinterviewswill
bebasedonorderofapplicationsreceived.

Please keep this page and copies of all the documents you submit for your own records.

Pleasenotethatsomeapplicationpages(*)mustbenotarized

Sister Cities Association of Springfield, Illinois

Phone: 217-622-4622
Email: scasilinc@aol.com

2015 SCAS 25th Anniversary


Student Delegation Ashikaga

Student Delegation Travel


Dates: June 19-29, 2015

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)
FirstName:

LastName:

Nickname(ifany):

DateofBirth(MM/DD/YY):

State:

HomePhone:
Familyemail:
Current
Grade:

StreetAddress:
City:

School:

StudentCellPhone:

Studentemail:

ZipCode:

Graduation
(MM/YY)

Parent(s)orLegalGuardian(s)
Parent1/Guardian1

FullName:
Address:
Occupation:
HomePhone:
CellPhone:
WorkPhone:

Parent2/Guardian2
FullName:

Address:

Occupation:

HomePhone:

CellPhone:

WorkPhone:

PeopleinStudentsHousehold
Pleasetellusthenamesandassociatedinformationofeveryonewhocurrentlylivesinthesamehouseasyoudo.
Youdonotneedtolistyourselforyourparents/guardians.
FullName
(firstname
RelationshiptoYou
Occupation(ifretired,occupationbeforeretiring)
lastname)

Age

APPLICATIONpg.1

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Phone: 217-622-4622
Email: scasilinc@aol.com
Student Delegation Travel
Dates: June 19-29, 2015

Whydoyouwishtoparticipateinthisprogramasastudentdelegate?

AreyoufamiliarwithJapanorwithSpringfieldsSisterCityprogramwithAshikaga? YesNo

Ifyes,inwhatway?

HaveyoubeeninvolvedinSpringfieldsSisterCityactivities? YesNo

Ifyes,describeyourinvolvement:

ListallyourForeignLanguages(ifany)
Howlonghaveyoustudied?
Speak?

Language

Read?

DoyouhaveaPassport?

YesNo

Ifyes,whatisthedateofexpiration(MM/DD/YY):

HaveyouevertraveloutsidetheUnitedStates? YesNo
When

Where

Ifyes,whenandwhere:

APPLICATIONpg.2

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Student Delegation Travel


Dates: June 19-29, 2015

StudentExchangePrograms
HaveyouparticipatedinotherstudentexchangePrograms?
YesNo
Year
Program/Location

Ifyes,whenandwhere:

Haveyoueverhostedaninternationalpersoninyourhome?
Year
Program/CountryofGuest

Phone: 217-622-4622
Email: scasilinc@aol.com

YesNo

Ifyes,whenandfromwhere:

AllAboutYou
Whatareyour
favoritesubjects?

Whatschool
activitiesareyou
involvedin?

Whatcommunity
activitiesareyou
involvedin?

Howdoyouliketo
spendyour
leisure/recreational
time?Hobbies?
Whatother
informationabout
yourselfwouldyou
liketosharewith
us?

Listtwoteachers,counselors,orprincipalswhoknowyouasreferences:
Name
WorkTitle
School

PhoneNumber

Doyouhavemedicalproblemsweshouldbeawareof?YesNoPleaselistallergies,dietaryrequirements,andany
medicationsyoumayneedtotake.

Iwishtobeconsideredforfinancialassistanceandwillprovidefinancialrecordsifacceptedasadelegate.YesNo

SIGNATURES

StudentSignature

Date

ParentorGuardianSignature

Date

APPLICATIONpg.3

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Phone: 217-622-4622
Email: scasilinc@aol.com
Student Delegation Travel
Dates: June 19-29, 2015

BASICPOLICIESFOREXCHANGESTUDENTS

SCHOOL:Studentsareexpectedtoattendschoolregularlyforthreedays,doassignedhomework,andtakework
seriously.Youareencouragedtoparticipateinschoolactivitiesandtogetmoreacquaintedwithotherstudents.You
willbeviewedasambassadorsfromourschoolandfromSpringfield.
ILLNESS:Intheeventofillness,doasyourhostfamilyadvises.Ifemergencytreatmentisrequiredoryoubecome
seriouslyill,yourhostfamilywilladvisethedelegationchaperones,thelocalcoordinator,and/oryourparents.
PASSPORT:Keepyourpassportinasafeplace.Carryitwithyouonlywhenneeded(duringinternationaltraveland
whenyouaregoingtoexchangedollarsortravelerschecksforyen.)
DRIVING:Studentsarenotpermittedtodriveanymotorizedvehicle.ThedrivingageinJapanis18.
WORK:Youmaynotworkwhileyouareanexchangestudent,althoughyouwillbeexpectedtodoroutine
maintenanceworkatschool.
HOMESTAY:Whilestayingwithyourhostfamily,youwillbeexpectedtoparticipateinfamilylife,whichmayinclude
performingroutinehouseholdtasksorchores.Bealerttothefactthatyourhostfamilywillhavefamilyrulesby
whichyouareexpectedtoabideandthatyourhostfamilymayhaveadifferentapproachtoyoungpeoplethandoes
yourownfamily.Theywillprobablyconsultyouaboutyourwishes,andyouwillgettogetherwiththeotherdelegates,
butdonotexpecttohangoutortotalkonthephoneasyoumightintheUSA.
TRAVELORTRIPS:Duringtheexchangeyoumaytravelwithyourhostfamilyorparticipateinotherorganizedtrips
(AshikagaCityusuallytakesthestudentstoNikkoNationalForest,whichisinthenearbymountains).Youmaynot
travelalonetodistantpoints.Hitchhikingisnotallowed.
ALCOHOLANDDRUGS:Thedrinkingofalcoholisnotallowedduringtheexchange.Legaldrinkingageis21inJapan.
Drugs,otherthanthemedicinessentbyyourUSAparent/guardiansorprescribedbyyourdoctor,areforbidden.Japan
hasa98%convictionratefordrugabuse.
RECIPROCITY:TheSisterCitiesAshikagaCommitteeexpectsyourfamilytohostastudentfromAshikagaaspartofyour
continuingparticipationinandsupportoftheprogram.
WORKSHOPS:ParticipationinuptofiveworkshopsonJapanesecultureandAmbassadorshipisrequired.
Parents/guardiansareencouragedtoattendallsessionsandarerequiredtobeatthefirstsession.Youwillreceivea
schedulewithyouracceptanceletter.

SisterCitiesAssociationofSpringfieldreservestherighttointerviewprospectivestudents,makefinalselectionsor
disqualifyaparticipantpriortodepartureorduringthetripfornoncompliancewithanyoftheSCASpolicies.

IHAVEREADTHESEPOLICIES.IAGREETOABIDEBYTHEM.IUNDERSTANDTHATMYFAILURETOADHERETOTHESE
POLICIESMAYRESULTINMYBEINGSENTHOMEATANADDITIONALCOSTTOMYFAMILY.

StudentSignature:
Date:

WEHAVEREADTHESEPOLICIES.WEUNDERSTANDTHATOURCHILDSFAILURETOABIDEBYTHEMWILLRESULTIN
HIS/HERBEINGSENTHOME.WEUNDERSTANDTHATINSUCHANEVENTWEARERESPONSIBLEFORANY
ADDITIONALEXPENSESINCURRED.

Parent/GuardianSignature
Date:

BASICPOLICIESFOREXCHANGESTUDENTSpg.4

Sister Cities Association of Springfield, Illinois


2015 SCAS 25th Anniversary
Student Delegation Ashikaga

Phone: 217-622-4622
Email: scasilinc@aol.com
Student Delegation Travel
Dates: June 19-29, 2015

MEDICALREPORTFORM

Thisistocertifythat__________________________________hasbeenexaminedbyaphysician
duringthislastyearandisfittotravelandtoparticipateinastudentexchangeprogramin
Ashikaga,Tochigi,Japan.

Parent/GuardianSignature

Date:

MEDICALREPORTFORMpg.5

Sister Cities Association of Springfield, Illinois

Phone: 217-622-4622
Email: scasilinc@aol.com

2015 SCAS 25th Anniversary


Student Delegation Ashikaga

Student Delegation Travel


Dates: June 19-29, 2015

EMERGENCYINFORMATIONFORMSCAS
Intheeventofinjuryorillnesstoourson/daughter
bornon
,weauthorizeJanetK.KenneyandJamesChipman,thechaperones
(andifnecessaryalternatechaperone,LillianR.Groesch)ofthestudentdelegationfromSpringfield,IL
toAshikaga,Japan,oranyonetheyauthorize,tosecuretreatment,deemednecessary,includingthe
administrationofananestheticand/orsurgery.

Parent/LegalGuardianSignature
Notarizedon

in

Date
,IL

By

Medicinesoranestheticstowhichourchildisallergicare:

Whatmedicalconditions,ifany,doesyourchildhavethataphysicianshouldtakeinto
considerationintheeventofanemergency?

EMERGENCYCONTACTS,ADDRESSES,ANDPHONENUMBERS
Thesepeoplewillbecontactedintheeventofanemergency,ifweareunabletoreachparents/guardians:
Name:
Relationship:

Address:
City:

DayPhone:
EveningPhone:

Name:
Address:
DayPhone:

Relationship:

City:

EveningPhone:

Attachphotocopy/scanofbothsidesofinsurancecard
InsuranceCompany:

PolicyNumber:

NameofPersonInsured:
EMERGENCYINFORMATIONFORMSCASpg.6

EMERGENCYINFORMATIONFORMJapan
Onrareoccasions,anemergencyrequiringhospitalizationand/orsurgerydevelops.Sinceminorsmay
not,asarule,beadministeredananestheticorbeoperateduponwithoutconsentoftheparent(s)or
guardian(s),werequestthatparent(s)orguardian(s)completethefollowingstatement.Thisisa
safeguardtopreventadangerousdelayinthecaseofanyemergencyandintheeventthatweare
unabletocontacttheparent(s)orguardian(s).
Intheeventofinjuryorillnesstoourson/daughter
bornon
,weherebyauthorizeAshikagaBoardofEducationandCityof
Ashikagatosecuretreatmentdeemednecessary,includingtheadministrationofananestheticand
surgery.

Notarizedon

Parent/LegalGuardianSignature
in

Date
,IL

By

Medicinesoranestheticstowhichourchildisallergicare:

Whatmedicalconditions,ifany,doesyourchildhavethataphysicianshouldtakeinto
considerationintheeventofanemergency?

EMERGENCYCONTACTS,ADDRESSES,ANDPHONENUMBERS
Thesepeoplewillbecontactedintheeventofanemergency,ifweareunabletoreachparents/guardians:
Name:
Relationship:

Address:
City:

DayPhone:
EveningPhone:

Name:
Address:
DayPhone:

Relationship:

City:

EveningPhone:

EMERGENCYINFORMATIONFORMJAPANpg.7

Sister Cities Association of Springfield, Illinois

Phone: 217-622-4622
Email: scasilinc@aol.com

2015 SCAS 25th Anniversary Student Delegation Ashikaga


Student Delegation Travel Dates: June 19-29, 2015

WaiverofResponsibility SisterCitiesAssociationofSpringfield,Illinois
We,

and

theparents/legalguardiansof

,herebyagreetothe

followingbyaffixingoursignaturesbelowonthisdate:

WeherebyreleaseJanetK.KenneyandJamesChipman(andifnecessaryalternatechaperone,LillianR.
Groesch);theSisterCitiesAssociationofSpringfield,IL,Inc.,itsBoard,andOfficers:theCityofSpringfield;
andSisterCitiesInternationalfromanyresponsibilityfortheactionsofourson/daughterduringtheyouth
exchangebothintheU.S.andinJapan.Further,weagreetoholdharmlessJanetK.KenneyandJames
Chipman(andifnecessaryalternatechaperone,LillianR.Groesch);theSisterCitiesAssociationof
Springfield,IL,Inc.,itsBoardandOfficers:theCityofSpringfield;andSisterCitiesInternationalfromany
liability,responsibility,damages,expenses,claims,lawsuitsorinjurieswhichmayoccurorbegivenriseto
duringhis/herparticipationintheyouthexchange.
Wehaveadequatemedicalandaccident,dismembermentandrepatriationinsurancecoverageforour
son/daughter.Wehaveverifiedthiscoveragewithouragentanditisvalidoverseas.Weareableto
providedocumentationifasked.
Weagreetocompletethemedicalform.Additionally,wewillcompleteandreturntheconsentfor
emergencymedicalattention,shouldtheneedarise,forourson/daughter.
Weagreethatourson/daughterwillnotdriveanymotorizedvehiclewhileparticipatinginthisexchange.
WeacknowledgethatJanetK.KenneyandJamesChipman,thechaperones,(andifnecessaryalternate
chaperone,LillianR.Groesch)andtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbiddenall
studentexchangeparticipantstodrinkalcoholicbeverages,includingbeer,wine,andsake.We
acknowledgethatthechaperonesandtheSisterCitiesAssociationofSpringfield,IL,Inc.haveforbidden
theuseofanydrugsbytheparticipant,saveforthoseprescribedbyaphysician.

Parent/LegalGuardianSignature

Date

Parent/LegalGuardianSignature

Date

Notarizedon
By

in

,IL

WAIVEROFRESPONSIBILITYSCASpg.8

WaiverofResponsibility Japan
We,

and

theparents/legalguardiansof

,herebyagreetothe

followingbyaffixingoursignaturesbelowonthisdate:

WeherebyreleaseMr.HiroshiTakagi,SuperintendentofAshikagaBoardofEducation,andCityof
Ashikagafromanyresponsibilityfortheactionsofourson/daughterduringtheyouthexchangein
Japan.Further,weagreetoholdharmlessMr.Takagi,SuperintendentofAshikagaBoardof
EducationandCityofAshikagafromanyliability,responsibility,damages,expenses,claims,lawsuits,
orinjuriesthatmayoccurorbegivenrisetoduringhis/herparticipationintheyouthexchange.

Wehaveadequatemedicalandaccident,dismembermentandrepatriationinsurancecoverageforour
son/daughter.Wehaveverifiedthiscoveragewithouragentanditisvalidoverseas.Weareableto
providedocumentationifasked.
Weagreethatourson/daughterwillnotdriveanymotorizedvehiclewhileparticipatinginthisexchange.
WeacknowledgethatJanetK.KenneyandJamesChipman,thechaperones;andtheSisterCities
AssociationofSpringfield,IL,Inc.haveforbiddenallstudentexchangeparticipantstodrinkalcoholic
beverages,includingbeer,wine,andsake.WeacknowledgethatthechaperonesandtheSisterCities
AssociationofSpringfield,IL,Inc.haveforbiddentheuseofanydrugsbytheparticipant,saveforthose
prescribedbyaphysician.

Parent/LegalGuardianSignature

Date

Parent/LegalGuardianSignature

Date

Notarizedon
By

in

,IL

WAIVEROFRESPONSIBILITYJAPANpg.9

Sister Cities Association of Springfield, Illinois

Phone: 217-622-4622
Email: scasilinc@aol.com

2015 SCAS 25th Anniversary Student Delegation Ashikaga


Student Delegation Travel Dates: June 19-29, 2015

AUTHORIZATION

IherebygivepermissionfortheSisterCitiesAssociationofSpringfield,Illinois,Inc.(SCAS)touse
photographsofmeoranyofmywrittencomments,writings,andevaluationsaboutmyparticipationin
SCASactivities,events,andtrips.SCASmaypublish,noworinthefuture,suchphotographsandwritten
materialstopromoteSCASactivities,asSCASdeterminesappropriate.

SCASDelegationMember(PrintFullName)

Signature,SCASDelegationMember

Parent,SCASDelegationMember(PrintFullName)

Signature,Parent,SCASDelegationMember

IfDelegationMemberislessthan18yearsofage,

AUTHORIZATIONpg.10