Lille Exchange Program Application to travel to Lille Please read over all forms carefully and complete all sections of the application before returning it to Mrs. Thomasson. While hosting a Lille student in the Fall is not required, it does enhance the exchange experience. Preference is given to HHS students who have previously hosted a student from Lille.
Hamburg Central School District 4111 Legion Drive Hamburg, NY 14075 District School Exchange Student Application of Intent to Travel (to be completed by student AND parent) Date of Application Age I. Student Information: Name D.O.B. Language Teacher Grade Current Level Address Home E-mail Address Cell II. Parent Information (please indicate preferred phone number in case of emergency) Name Address Employer Home Work Cell E-mail Address Name Address Employer Home Work Cell E-mail Address Name and phone number of person/s to be contacted in case of emergency (other than parents): ( ) Relationship to student:
Recommendation for Travel Please choose three adults (at least 1 current or recent teacher, your Guidance Counselor and one other member of the community who knows you well) and provide their contact information. They may be contacted with questions about your ability to adapt to living overseas for two to three weeks. TEACHER: Email Address: Phone Number: GUIDANCE COUNSELOR: Email Address: Phone Number: OTHER: RELATIONSHIP: Email Address: Phone Number: Return of applications and notification of acceptance Applications and a deposit payment are due. Please make checks payable to Visions Travel. Students will be notified as soon as possible of their acceptance. Applications received after the due date will be considered on a space-available basis. Program cost may be significantly different for late applicants due to instability of airline prices.
Statement of Commitment Please read carefully I understand that, while participating in the exchange, I will be representing my family, school, community and country. I am expected to behave in a manner that will make everyone feel proud of me and of our exchange group. I understand that this is a school sponsored exchange, and that I will comply with all rules and expectations set forth by the trip advisors and chaperones. I have read and understood the Code of Conduct. I also understand that the cost of the program is significant and, if accepted, I will be able to handle this financial obligation. My signature below indicates that I understand and accept these responsibilities. Student Signature Date Parent Signature Date Parent Signature Date Application Questions Please type your answers on a separate sheet, or e-mail them to Mrs. Thomasson at: jthomasson@hamburgschools.org 1. Please explain the benefits you expect to gain from participating in a school exchange abroad. 2. How do you feel about living away from your friends and family for an extended period of time? 3. As an ambassador of your family, school and community, what can you offer your host family? What will they gain from having hosted you as an exchange student? 4. What kind of person are you? Easy to live with? Difficult to live with? What would your family say about you? Why? What are your best qualities? Your worst habits? 5. How will you share your experiences once you return home?
RULES AND CONDUCT CODE My son/daughter: has my permission to participate in the exchange and trip to Lille, France. This trip is school-sponsored and thus all school rules are in effect throughout the duration of the exchange. The undersigned further understands and agrees with the RULES AND CONDUCT CODE as follows: Expected Behavior: 1. The student will attend school and field trips as specified by the teachers. The student agrees to attend classes daily with his/her assigned French host student. Students not attending appropriate classes and participating as fully as possible will be subject to HHS Level 1 Academic Misconduct disciplinary actions upon return to HHS. 2. Mature, courteous, thoughtful behavior and conduct of highest quality is expected at all times, both in school and with your host family. Discuss house rules (curfew times, procedures for calling home, etc.) with your French family. Remember that you are representing Hamburg High School throughout the duration of your stay in France. Students not meeting the expected level of conduct will be subject to HHS Level 2 Disruptive Behavior disciplinary actions upon return to HHS. 3. The student is expected to obey all rules, time schedules, and safety precautions established by the teachers during the travel and group activities. 4. The student agrees not to obtain any piercings, tattoos, etc. during the exchange. 6. Hamburg High School s Zero Tolerance policy regarding alcohol is in effect throughout the duration of the exchange. The possession, use or sale of alcohol will be considered as unacceptable behavior and will result in immediate notification of the parents and possible return to the United States at the expense of his/her parents. 7. The student is not allowed to drive a car or other motorized vehicle in France. Any driving will be considered as the illegal operating of a motor vehicle and will be reported to the local authorities. 8. Use, purchase, or possession of drugs or illegal substances will result in the participant s immediate return to the United States at the expense of his/her parents. In the case of arrest, the student becomes the total responsibility of his/her parents. Date: Parent Name Printed: _ Parent Signature: I, have read the above rules and conduct, and agree to be bound by them. Student Signature
Parent Permission Form For Internet Publishing of Student Work or Images Requirements for Posting Student Work or Images Prior to the publication of any form of student work or pictures on the Internet, each student must have a parent permission form on file with their classroom teacher. Name of Student: Grade: We understand that our child s picture or original work may be published on the Hamburg Central School Website. A home address or telephone number will not appear with such pictures or work. Permission to Publish on the Internet Choose all the apply: Yes No You may publish my child s original work. You may publish my child s first name. You may publish my child s first name and last name. You may publish my child s photograph. This permission will remain in effect until we request in writing that the picture or original work be removed. When requested, the artwork or picture will be removed within one week of receipt of the request. We understand that the picture or original work may be removed at the decision of the District at any time. Student Signature: Date: Parent/Guardian Name: Date: (Printed) Parent/Guardian Signature: Date:
Release and Agreement We, the undersigned, agree to the following: 1. I agree to release the district-approved chaperones, the Hamburg Central School District, and the Ensemble Scolaire Thérèse d Avila from, and not to hold such parties responsible for, any claims, demands, liabilities, or causes of action arising out of, or connected to, personal injury, illness, death, or property damage resulting from any cause whatsoever. I agree to indemnify, defend, and hold harmless the above named from any damage resulting from events over which they exercise no control, such as Acts of God, strikes, or government restrictions. I further agree to indemnify said parties from any claims, liabilities, costs, or expenses arising out of personal injury or property damage that I either cause or contribute to while participating in the exchange between the Hamburg Central School District and the Ensemble Scolaire Thérèse d Avila, and from any financial obligations which I may incur of my own behalf. 2. The right is reserved to make changes to the exchange program for the safety, comfort, or convenience of members of the exchange group whenever, in the judgment of the chaperoning teachers, such changes are deemed necessary. That right is further reserved to refuse to accept or retain any person as a member of this program, either prior to departure or during the course of the exchange visit. 3. No responsibility is incurred by the district-approved chaperones for loss of passport, airline or train tickets or other documents, or damage to luggage or any personal belongings. 4. If I become ill or incapacitated, the district-approved chaperones may take actions necessary for my safety and well-being, including securing medical treatment and transporting me home at my own expense. I fully release the district-appointed chaperones, the Hamburg Central School District, and the Ensemble Scolaire Thérèse d Avila from any liability for such action as may be taken on my behalf. 5. This agreement will be governed by the laws of the State of New York. 6. I have read this RELEASE AND AGREEMENT, fully understand it, and agree to be bound by the terms herein. Signture of Parent/Guardian Signature of Parent/Guardian Signature of Student Date Date Date
ADDITIONAL RELEASE OF DISTRICT-APPROVED CHAPERPONES In consideration of your agreement to act as Teacher/Chaperone for my child,, during the exchange to Lille, France, I do hereby agree to hold you, your heirs, executors and administrators free from any and all liability, and do hereby for myself, my heirs, executors and administrators waive, release and forever discharge any and all rights and claims for damages which I or my child may have or which may hereafter accrue to me, or my child arising out of or in connection with your capacity as a Teacher/Chaperone or with your participation in any activities during the exchange to Lille. I shall indemnify you against expenses, judgments, fines, settlements, and other amounts actually and reasonably incurred in connection with any proceedings or potential proceedings arising out of the acts whether negligent or intentional of my child during the time which you are acting as Teacher/Chaperone on the exchange to Lille. I shall advance to you any defense expenses in any such proceeding. I do hereby declare myself to be physically and mentally sound and am capable of entering into this agreement. Printed Name of Student Printed Name of Parent/Guardian Parent/Guardian Signature Date
MEDICAL PERMISSION SLIP (Please print) Name: last first middle Address: AGE DOB: / / Home phone: Parent e-mail: Medical insurance company name: Policy/Group Number Student s Physician s Name Physician s Phone Special Health Concerns (Including Food and other Allergies) Medications and Dosage per Day
Asthma? (Y/N) Medication/Dosage: Diabetes? (Y/N) Medication/Dosage: Epilepsy? (Y/N) Medication/Dosage: Should you be restricted from any type of activity? Y/N If yes, please explain: Are there any drugs (prescription or non-prescription) that should NOT be administered? NOTE: If you are taking medication regularly, please be sure you bring an adequate supply in the original container AND a copy of the prescription for those medications. We, the undersigned parent(s) or guardian(s) of authorize the chaperones and/or host parents of the Hamburg Central Lille Exchange to obtain medical care for our child in the event such care is necessary. If possible, the parent(s) or guardian of the named individual will be contacted in the case of an emergency. Permission is hereby granted to the licensed physician or hospital and its associates to perform any medical and/or surgical procedures that are determined essential to the treatment of the above-named individual. We also agree that we are responsible for payment of such care. Signed: Parent or Guardian: Date: Parent or Guardian: Date: