ࡱ> XZWY hbjbjWW &8==h]|||||||D         = $  |      \||   \\\  | | |||| \8\V^p||  )dF   Lions Clubs MD 37 Youth Exchange Program Applicant and Sponsoring Club Form, 2002 I.D. No. Instructions: Please print clearly or type. The applicant, his/her parents or guardians, and the sponsoring Lions Club Officers shall complete appropriate sections of this form. After approval by the sponsoring Lions Club, the application shall be forwarded to the District YE Chairman. Three passport-size colour photographs of the applicant along with a $1000.00 deposit, payable to MD 37 Youth Exchange must accompany application.Photo PART I. Applicants Information Country of Choice for Exchange: Male Female 1st Preference2nd Preference Applicant Personal Data Name: Address: Street City Province Country Postal Code Phone Email Address __________________________ Date/Place of Birth School Now Enrolled In Field of Study/Career Objective Hobbies/Special Interests Awards/Honors Language Spoken: English _______ French _______ Other________ Religion __________________________ Health Conditions ___________________________________________________ Medical/Dietary Requirements Medications (Prescription & Over the Counter)_____________________________________________________ Allergies___________________________________________________________________________________ Leo Club Member ( Yes ( No Club Do you smoke? ( Yes ( No Dates and countries of previous trips abroad Have you ever participated in a Lions Youth Exchange Program? If so, when? Sources for Financing Visit (Please specify) Agreement to Terms of Program If accepted to participate in the Lions Youth Exchange program, we will abide by its policies and procedures and further agree to the following Rules for Participants and understand that any serious violation of these can result in my/our son/daughter/ward being returned home at my/our expense: No use of drugs or alcohol will be tolerated No romantic involvements No driving of any motorized vehicles in foreign lands Nothing shall interfere with our familys hosting responsibilities Participation in this program is not for the purposes of tourism, formal education or employment. Extended personal travel or leaves of absence for any reason are not permitted before, during or following the program, unless such travel is authorized in this application. Signature of Applicant Date Signature of Parent or Guardian Date PART II. Parent/Guardian Information and Authorization Family Data Fathers Name Occupation Address Telephone Lions Club Member? ( Yes ( No Club Mothers Name Occupation Address Telephone Lions Club Member? ( Yes ( No Club Other family members (give age/relationship) Authorization to Travel With the affixed signatures, I/we the parents(s) of authorize my/our son/daughter/ward to travel to and remain at an approved place and for an approved period living in Lions or Lions approved homes. I/we authorize/do not authorize our son/daughter/ward to travel on his/her own outside the Lions Youth Exchange Program. If authorized, I/we will arrange for financing of this extended travel, and understand that he/she will be covered under the Program insurance policies only while travelling or resident under the Program. I/we have therefore arranged for comprehensive medical, life, accident, personal property and liability insurance to cover his/her entire stay in the country(s) to be visited, as follows: Name/address of Insurance Company Policy No. Parents or Guardian Signature Date Authorization for Emergency Medical Treatment I/we the parent(s) or guardian(s) authorize and give legal consent for the Lions Youth Exchange official or the family hosting my/our son/daughter/ward to take immediate necessary action in medical or surgical emergencies when time does not permit the obtaining of consent by me/us, and when such medical treatment is prescribed by a doctor. Parents or Guardians Signature Date PART III Indemnity Agreement As the parents or guardians of we give permission for our son/daughter/ward to travel to and remain at an approved place for a specified period of Lions or Lions approved homes or Lions camps. I agree to relieve any Lions member or host family, Lions Club, Lions District or Lions International of any financial or other expenses incurred. I also agree that the son/daughter/ward will not be permitted to drive a motor vehicle while away under this Youth Exchange Program. The son/daughter/ward will return to his/her home at the completion of the exchange unless I send written permission and financial means and designate where else the son/daughter/ward is to go. In such instances the Lion supervision will cease when the son/daughter/ward leaves the home of the Lions host or the Lions Camp. Furthermore agree we will comply with the rules of the program. In the case of violation of the rules, we understand and accept that our son/daughter/ward will be returned to his/her home. Fathers or Guardians Signature Date Mothers or Guardians Signature Date Applicants Signature Date PART IV Certification of Sponsoring Lions Club President or Club YE Chairman Club Name District Address City Province/State Country I certify that the applicant is qualified to participate in Lions Youth Exchange Program and that he/she and his/her family have been fully informed of the programs regulations and objectives. Signed Appointment Date Name (print or type) Telephone Address PART V Endorsement by Sponsoring District Youth Exchange Chairman I have reviewed this application and give my endorsement. Signed Date Name (print or type) District Address Telephone ;<&=DEVX^_ijtu-.   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