Student Delegation Application

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)




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




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




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




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




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:




MEDICALREPORTFORMpg.5

MEDICALREPORTFORMThisistocertifythat__________________________________hasbeenexaminedbyaphysicianduringthislastyearandisfittotravelandtoparticipateinastudentexchangeprograminAshikaga,Tochigi,Japan.Parent/GuardianSignature Date:




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:


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


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.



Notarizedon in ,IL

By


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

Documents

Student Delegation Application