WENDELL FISH STUDENT EXCHANGE PROGRAM

 

NEWPORT BEACH, U.S.A. – OKAZAKI, JAPAN

 

 

 

STATEMENT  OF  INTENT / RELEASE - OKAZAKI  (PART  D)

 

CONFIDENTIAL

 

Instructions:  This is a sample form.  Obtain current year instructions from the Ensign School and Corona del Mar Middle School offices.                      

Please note:  The 4-Part Application Form is only valid once the original, signed Statement of Intent/Release is received per the instructions referenced above.

 

I.  STATEMENT OF INTENT

 

I am interested in my son/daughter being considered for the reciprocal student exchange experience to Okazaki, Japan.

 

STUDENT’S NAME: ___________________________________________________________

 

SCHOOL         ______________________________________________  GRADE: _________

 

HOME ADDRESS:      _________________________________________________________

                                   

                                    _________________________________________________________

 

HOME PHONE: __________________________________WORK PHONE:________________

 

CELL PHONE:  ___________________________________________

 

E-MAIL ADDRESS:  ____________________________________________________________

 

With my signature, I hereby acknowledge that my son/daughter is interested in participating in the reciprocal student exchange program between the cities of Newport Beach, CA and Okazaki, Japan (“Wendell Fish Student Exchange Program”).  I also acknowledge that I have reviewed:

·         The Information and Instructions, and

·         The Application Form of my son/daughter and that the information given is correct.

 

I further acknowledge and agree that the Wendell Fish Student Exchange Program is based on reciprocity and that I agree to host as part of our family from October 3 to 10, 2006 the Japanese student at whose house my son/daughter will have stayed while in Japan. 

The Newport Beach Sister City Association will procure medical travel insurance from July 10 to 20, 2006 on behalf of the students.  Cost for the medical travel insurance will be borne by the parents.

 

______________________________________________________________________________

Parent/Guardian Name (Print)                                        Signature                                 

 

Date:  _____________________________________

 

 

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II.   MEDICAL INFORMATION

 

Please indicate below whether your son/daughter is on any prescription medication that he/she will be taking while staying in Japan. 

 

Name of Prescription Drug /  Dosage and Frequency of Consumption: 

 

_______________________________________________________________________

 

_______________________________________________________________________

 

 

Can your son/daughter administer the drug by him-/herself:         Y          N         N/A      (Pls circle)

 

Please indicate whether your son/daughter has any allergies/adverse reaction, such as to bee stings, penicillin, milk/milk products, that need any medical attention

 

Allergic/Adverse reaction:  ___________________________________________________________

 

What is the typical treatment? ___________________________________________________________

 

 

Is your son/daughter traveling with the necessary medication      Y         N         N/A      (Pls circle)

 

 

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III.  FINANCIAL SUPPORT

 

The cost to you to send your son/daughter to Okazaki is approximately $1,600.  For financially needy students, the NBSCA has provided contributory funding so that qualified candidates can go.

 

Are you planning on asking the NBSCA for funding?                   Y         N         N/A      (Pls circle)

 

If Yes, please indicate the range of funds that you are able to contribute:  $_________________

 

Should your son/daughter be selected and you have expressed an interest to apply for financial support, the NBSCA will contact you.  Please note that this information will be held strictly confidential.

 

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IV,    RELEASE FORM

 

Student’s Name: ____________________________________________________________

 

Parents/Gardians Names: ______________________________________________________

 

Address:   ________________________________________________________________

           

                 _______________________________________________________________

 

Best Contact Telephone No.:  _(______)________________________

 

 

In consideration of accepting the Wendell Fish Student Exchange Program, 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, the Newport Balboa Rotary Club and any of the officers, agents or employees of the above listed entities 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.

 

I further agree to procure a family membership in the Newport Beach Sister City Association for the years 2006 and 2007.  The cost is approximately $50.00 per year.

 

Parent/Guardian:

 

_________________________________________________________________________    

                          Print                                                   Signature         

 

Date:    _____________________________________

 

 

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