Student Delegation Application

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

Phone: 217-622-4622
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
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
Phone: 217-622-4622


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

Phone: 217-622-4622
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


Dates: June 19-29, 2015
StudentExchangePrograms
HaveyouparticipatedinotherstudentexchangePrograms?
YesNo
Year
Program/Location
Ifyes,whenandwhere:
Haveyoueverhostedaninternationalpersoninyourhome?
Year
Program/CountryofGuest
Phone: 217-622-4622
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

Phone: 217-622-4622
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

Phone: 217-622-4622
Dates: June 19-29, 2015
MEDICALREPORTFORM
Thisistocertifythat__________________________________hasbeenexaminedbyaphysician
duringthislastyearandisfittotravelandtoparticipateinastudentexchangeprogramin
Ashikaga,Tochigi,Japan.
Parent/GuardianSignature
Date:
MEDICALREPORTFORMpg.5
Phone: 217-622-4622


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
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
Phone: 217-622-4622
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.
Date
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.
Date
Date
Notarizedon
By
in
,IL
WAIVEROFRESPONSIBILITYJAPANpg.9
Phone: 217-622-4622
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

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ApplicationPackage

Sister Cities Association of Springfield, Illinois

Sister Cities Association of Springfield, Illinois

Sister Cities Association of Springfield, Illinois

2015 SCAS 25th Anniversary

Student Delegation Travel