EXCHANGE PARTICIPATION & TRAVEL
FORMS
2009 - 2010
The information enclosed in the application packet will be used only for exchange purposes and will be destroyed in the
manner of other confidential information once the exchange is completed.
Ketchikan-Kanayama Exchange -- P.O. Box 6774 -- Ketchikan, AK 99901
Student Exchange Required Forms
Applications must be postmarked or turned into Schoenbar Office by September 30, 2009 to be considered, and
must be complete with the following:
Student Application and Questionnaire (includes housing information)
Parent Questionnaire
Participation Fee and Participation Fee Refunds Form
Travel Authorization, Medical Authorization, and Liability Release
Medical Review Form
Ketchikan-Kanayama Student Exchange Activity Agreement
Ketchikan-Kanayama Student Exchange Contract
Copy of seventh grade transcript/report card
Five recommendations mailed directly to the Exchange Committee at:
P.O. Box 6774, Ketchikan, AK 99901
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PARTICIPATION FEE & PARTICIPATION FEE REFUNDS
FINANCIAL COMMITMENT: For those selected to take part this exchange, this is a trip of a lifetime, However, travel to and within Japan
is expensive. For this reason, you need to be fully aware of the financial and time commitment involved. Students selected for the
exchange must be able to commit to a base monetary amount of $1800. Commitment amount is evaluated yearly and adjusted based
on higher or lower projected travel expense. This money is used to help cover airfare, train tickets, meals, and any necessary overnight
stays for the basic trip to Kanayama, Japan.
PAYMENT OF PARTICIPATION FEE: While the participation fee is only part of the overall fundraising effort, it does form a substantial
part of the amount we pay for the purchase of airline tickets.
The monetary commitment is broken down into 4 monthly commitments of $450, payments must be complete by March 31, 2010 in order
to complete travel plans and ticket purchases. (Chaperones selected also pay this monetary commitment.)
PARTICIPATION FEE REFUNDS: Prior to making any payments to the airline to secure our group airfare, any participation fee paid in for
a student or chaperone dropping from the program is fully refundable.
The deposit to secure our group airfare, usually $100 per person is paid to the airline in March. The participation fee paid in for a student
or chaperone dropping from the program after the airfare deposit is made, will receive a full refund, less the deposit which was forfeited to
the airline.. In the chance that the airline does not retain the deposit, the amount will also be refunded.
The tickets we purchase are based on group fares and are non-refundable. If the tickets purchased is not used for any reason, the
participation fee is not refundable.
A purchased ticket is valid for one year and for a fee charged by the airline, the name can be changed or the ticket value applied to other
travel. If you wish, you may purchase the unused ticket by paying the difference between the participation fee and the actual value.
Any funds remaining in the total budget upon completion of the travel will revert to the exchange program to help cover costs and
ensure its future continuation and viability, and there will be no refunds upon trip completion.
I understand the above criteria for fees and refunds.
Parent Signature: _________________________________________________________ Date: ____________________________
Parent Signature: _________________________________________________________ Date: ____________________________
Student Name: ______________________________________
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KETCHIKAN – KANAYAMA EXCHANGE ASSOCIATION
TRAVEL AUTHORIZATION, MEDICAL AUTHORIZATION, AND LIABILITY RELEASE
PARENT/GUARDIAN: This is a legal document, which may affect your rights and your child’s rights in the event that an accident or illness
occurs and your child is injured while on any of the Kanayama Exchange events. If you have any questions about this document, you
should consult legal counsel. The document also constitutes consent to medial treatment for your child while he/she is away. Your
agreement to the conditions of this release is required if you and/or your child elect to participate in the exchange program.
I. STUDENT INFORMATION
Student Name: __________________________________________________ Home Phone: ___________________________
Parent/Guardian Name: ___________________________________________ Work Phone: ____________________________
Parent/Guardian Name: ___________________________________________ Work Phone: ____________________________
Mailing Address: ________________________________________________________________________________________
II. CONSENT: The above named child has my permission and consent to travel with the Ketchikan – Kanayama Exchange
Program and to participate in all the activities. I understand that this program is conduced outside the city of Ketchikan and
requires travel by both public and private means of transportation and that my child may be housed in either public or private
housing. I consent to these conditions.
III. MEDICAL AUTHORIZATION: I authorize treatment for my child by a medical doctor, hospital, and/or health clinic in the event of
illness or injury while he/she is traveling to and from, or while participating in, the Exchange Program described above, after an
unsuccessful attempt to contact has been made to reach me. I additionally authorize the chaperone(s) or person(s) housing my
child to contract in my behalf for, and to authorize medical treatment by a medical doctor, or hospital and/or health clinic and
consent to such treatment as fully and in the same manner as if I were present.
IV. RELEASE: In consideration of my child being permitted to travel with the Ketchikan-Kanayama Exchange Program and in further
consideration of the chaperones accompanying the group, and except to the extent prohibited by law or public policy, I do hereby
release, relinquish, waive and forfeit all claims of damage against the Ketchikan-Kanayama Exchange Program, directors,
agents, and employees. I also agree to hold harmless, indemnify, and agree to defend at my own expense, Ketchikan-
Kanayama Exchange Program, together with its directors, officers, agents, employees, and chaperones, from any liability or
claim of liability of any nature which may be asserted against said Ketchikan-Kanayama Exchange Program, directors, officers,
agents, employees, or chaperones, and regardless of the nature of the claim whether for personal injury, property damage,
emotional distress or other damages of whatever nature. This release and agreement to be held harmless applies to claims
which may arise out of my child’s travel to or from housing, lodging, medical treatment or participation in the above program. I
additionally agree that in the event health care treatment is required for my child and authorized by a chaperone or volunteer of
the Ketchikan-Kanayama Exchange Program or other such persons acting for the Program will be reimbursed for any expenses
incurred for such health care treatment. Finally, I agree to reimburse the Ketchikan-Kanayama Exchange Program for any
expense in behalf of my child for the transportation, housing, board or otherwise appropriate and incidental to the child’s
maintenance/care and support during his/her participation in the above program.
________________________________________ _____________________________________________ _______________________
Parent/Guardian Signature(s) Date
________________________________________ _____________________________________________________________________
Witness Address / Phone Number
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KETCHIKAN-KANAYAMA EXCHANGE MEDICAL REVIEW FORM
Student Name: __________________________________________________________ Birth date: ______________________________
Parent/Guardian Name: ___________________________________________________ Work/Cell Phone: ________________________
Parent/Guardian Name: ___________________________________________________ Work/Cell Phone: ________________________
Mailing Address: _____________________________________________________________ Home Phone: _______________________
Other Family/Friend Contact: ___________________________________________________ Phone: ____________________________
Family Physician: ____________________________________________________________ Phone: ____________________________
Insurance Information: Please complete or include a copy of current insurance card for the above student.
Insured’s Name: ________________________________________________ Guarantor: ______________________________________
Insurance Carrier: ________________________________________ Member #: ____________________ Group # __________________
Medical History: Please complete. Be as specific as possible.
Known allergies and sensitivities (including foods and medications) ________________________________________________________
______________________________________________________________________________________________________________
Any current medications: __________________________________________________________________________________________
Dosage/How often: __________________________________________________________________________________________
Special Diet: ___________________________________________________________________________________________________
History of Chronic/Recurrent Infections: ______________________________________________________________________________
______________________________________________________________________________________________________________
Activity Restrictions: _____________________________________________________________________________________________
______________________________________________________________________________________________________________
Any past history of serious illness/injury that we may need to be aware of? ___________________________________________________
______________________________________________________________________________________________________________
History of motion sickness? ________________________________________________________________________________________
Are there any disabilities or limitations that we may need to be aware of? ____________________________________________________
______________________________________________________________________________________________________________
Any comments you wish to make concerning your child’s health status? _____________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Parent/Guardian Signature: _____________________________________________________ Date: _____________________________
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KETCHIKAN-KANAYAMA STUDENT EXCHANGE ACTIVITIES AGREEMENT
As a participant of this student exchange activity you are representing your family, your school, your advisors, and your community. You
will be expected to set the best example possible while you are participating in this program. Please review this form with your
parents/guardian. Return this agreement signed by your parent/guardian and yourself with your application.
ELIGIBILITY FOR PARTICIPATION IN STUDENT ACTIVITIES AND TRAVEL INCLUDES:
1. Must be a full-time 8th grade student in a recognized Public/Private School.
2. Must meet the requirements of ASAA (Alaska Student Activities Association) which we used as our guidelines.
3. Must have the following grade requirements:
a. C/2.0-grade minimum in order to travel
b. No F-grade during any/all grading period(s) (quarter/semester)
4. Use or possession of alcoholic beverages or drugs, including the use of tobacco, will result in being dropped from participation in
the program.
5. No gambling for money or participation in other illegal activities.
6. No switching of housing without chaperone approval when in host cities. Curfew regulations are set by the chaperone host
family, and/or town, and will be followed.
7. Must dress neatly and appropriately at all times, appropriateness will be reviewed by chaperones.
8. If suspended from school, the student may be dropped from the program after review by the exchange board.
9. Must be in place, on time, with proper materials at all times.
10. Must follow the guidelines set forth in the Ketchikan-Kanayama Student Exchange Contract
11. Additional rules and regulations may be added by the exchange board and chaperons as needed and students will be expected
to follow them.
12. Students who travel as part of this exchange program are viewed as representative of Ketchikan and must conduct themselves
accordingly. School rules shall apply to all students traveling under school sponsorship whether it is in another town, on the
ferry, or in an airplane.
13. Absolutely NO REFUNDS after tickets have been purchased if the student is dropped or withdrawn from the program for any
reason.
VIOLATIONS OF ANY OF THE ITEMS LISTED ABOVE MAY RESULT IN THE STUDENT BEING SUSPENDED FROM THE ACTIVITY
AND/OR BEING RETURNED HOME, ACCOMPANIED BY A CHAPERONE, AT THEIR OWN OR THEIR PARENT’S EXPENSE.
******************************
STUDENT ACTIVITIES AGREEMENT
I ___________________________________, have read and agree to comply with the rules as a member of the Ketchikan-Kanayama
(Student signature)
Exchange Program and the Ketchikan Schools.
I/We, __________________________________________ and __________________________________________ have read and
(Parent/Guardian signature) (Parent/Guardian signature)
understand that the above policies apply to my child while he/she is representing Ketchikan and Ketchikan Schools during the course of
this exchange program.
Date: ______________________________________________
(Ketchikan-Kanayama Student Exchange Activities Agreement adopted from the Ketchikan Public Schools Student Activities Agreement)
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KETCHIKAN-KANAYAMA STUDENT EXCHANGE CONTRACT
For Japanese Sunday School and for any other Kanayama events and travel . . .
I will be on time.
I will be an active participant.
I will write a self-introduction speech and learn it in Japanese
I will learn and join the group performance (songs/dances/skits)
I will use polite language.
I will be respectful of others, honest and responsible.
I will interact with other students and adults, and show that I am a team member.
I will not put-down Japanese food, culture or language, or other’s efforts to speak Japanese or English.
I will sit straight in class and at meals.
I will not wear jewelry or make-up.
I will wear socks and will remove my outdoor shoes at homes and schools.
I will wear appropriate indoor shoes for school and in homes.
I will not eat or chew gum on school grounds.
I will not groom myself in public.
I will follow rules and directions given by teachers and chaperones.
I will not leave the group unless a teacher or chaperone has given me permission.
I want to learn and have fun!
I will conduct myself honorably to avoid embarrassing my housing family, my group, and myself.
I will participate in all activities scheduled during the time in March when the Kanayama students are in
Ketchikan
Student signature: _____________________________________________________
Date: _________________________
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KETCHIKAN-KANAYAMA STUDENT EXCHANGE CANIDATE EVALUATION FORM
Due by September 30, 2009
Student’s Name: _________________________________________________________________
The above student is applying to be a part of the Ketchikan-Kanayama Student Exchange. He/She would like your evaluation of how you
think he/she will fit in with the group traveling. This information will be treated as CONFIDENTIAL and not shared with parent or student.
Please answer honestly and return to the address above. Thank you for your help in the selection process.
Your Name: ___________________________________________________________________________________
1. How long have you know this applicant and in what capacity (teacher, coach, family friend, etc.) _________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2. What characteristics or attributes best describe this applicant? ____________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
3. In what area(s) is the student most exceptional? _______________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. How well do you feel the student participates within a group? _____________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
5. How well does this student communicate with others (peers, adults, etc) _____________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
6. Is this student honest and trustworthy? _______________________________________________________________________
7. Does this student respect authority? _________________________________________________________________________
8. How well does this student tolerate differences and respect others within his/her peer group? ____________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
9. Is this student reliable and prompt? __________________________________________________________________________
10. Does this student show initiative in his/her actions? _____________________________________________________________
11. Does this student possess leadership skills? _________________________________________________________________
12. Does this student make decisions despite obvious peer pressure? _________________________________________________
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13. Would you have any reservations if you were accompanying this student on an extended trip to a foreign country?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
14. How would this student react if he/she were put in the spotlight? ___________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
15. Please make any other comments about your general impression of this applicant. ____________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Your Signature: _____________________________________________________ Date: _________________________
Phone Number: ___________________________________
Thank you for your time completing this form. This will help us in our student selection for this years group.
Please return to the Ketchikan-Kanayama Exchange Board by September 30, 2009
P.O. Box 6774 Ketchikan, AK 99901
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PASSPORT:
If you need to apply for a passport:
• Minors under age 16 must apply in person at the Post Office.
• All children regardless of age, including newborns and infants, must have their own passport
http://travel.state.gov/passport/get/minors/minors_834.html
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