STUDENT EXCHANGE APPLICATION FORM

I am interested in my son / daughter being considered for this reciprocal student exchange

experience with Antibes, France.

STUDENT’S NAME________________________________________________________

SCHOOL____________________________________________GRADE______________

HOME ADDRESS_________________________________________________________

__________________________________________HOME PHONE_________________

FAX_____________________EMAIL__________________________________________

PARENT / GUARDIAN SIGNATURE_______________________________________                                  

DATE  _____________________________________________________________

STUDENT EXCHANGE PROGRAM RELEASE FORM

PARTICIPANT’S NAME:________________________________________________________

Parents Name: _______________________________________________________________

Address: ___________________________________________________________________

State: _________________ Zip: ________________ Telephone: ______________________

In consideration of accepting this Student Exchange, I hereby agree to indemnify and hold harmless the City of Newport Beach, the Newport Beach Sister City Association, the Newport-Mesa Unified School District and any of its officers, agents or employees from any liability or claim or action for damages resulting from, or in any way arising out of, the participation in the program by the above participant.

The Newport Beach Sister City Association does not provide medical nor liability insurance. Please consult your own insurer regarding your coverage outside of the U.S.A.

(Parent or Guardian)

Signature: ___________________________________ Date: ______________________

      STUDENT PROFILE

Student’s Name:_________________________________________________________

Parents’ Names:_________________________________________________________

Address:________________________________________________________________

Telephone:___________________E-mail address: ____________________________

Student’s Age:______________ Student’s Birth Date:_________________________

School:___________________________________________  Grade:_______________

Number of years studying French:_______ Other foreign language(s):___________

GENERAL INFORMATION

Special Interests, Hobbies, Etc.:

Family Information:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Reciprocal Concerns (indicate one):   We would ____ / would not _____ like to see our child            participate in the program.

Our child is a:      Female________   Male __________

We would allow our son / daughter to host a Girl_________ Boy___________ Either_______

We would allow our son / daughter to stay with the family of a Girl____ Boy____ Either_____

Parent/Guardian Signature:_____________________________________________________

2010 Reciprocal Student Exchange with

Antibes, France