HAWAII LIONS INTERNATIONAL YOUTH CAMP
Application Form This form is for camp year 2016
Instructions: The applicant, his/her parents or guardians and the sponsoring officers should complete this form in full. Please attach:
1. Passport size photograph of the applicant
2. Applicant’s letter of introduction to prospective host family 3. Indemnity agreement signed 4. Copy of certificate of medical and accident insurance 5. Copy of passport
Forward original application to the camp director of the Hawaii Lions International Youth Camp and copies to sponsoring Lions Club and District YEC of sponsoring country. *****************************************************************************
A.PERSONAL DATA
Name______Male______Female______
Street Address______
City______Province/State______
Country______Post Code______
Telephone: Country Code______Area Code/Prefix______
Local Number______Email______
T-Shirt Size:Small______Medium______Large______Extra Large______
Date/Place of Birth______
School now enrolled in______
Field of Study______
Hobbies/Sports______
Can you speak English? Some______Good______Excellent______
Health Condition______
Medical/Dietary Restrictions______
Leo Club Member? Yes______No______If so, what club?______
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B.FAMILY DATA
To be completed by applicant’s parents or guardians. Please attach family photograph.
Father’s name______
Mother’s name______
Street Address______
Home Phone______Mobile Phone______
Lions Club Member: Yes______No______
Other family members? (Names, ages and relationship)
______
______
______
______
Will you permit your son/daughter to travel on his/her own in the host country after the completion of the Hawaii Lions International Youth Camp: Yes______No______. If yes, give places, dates of itinerary and final departure to home country. Who will finance the extended travel?
______
I understand that the Hawaii Lions International Youth Camp officials are not responsible for my son/daughter after the camp date. I further understand that no SPACE AVAILABLE airline tickets will be accepted. I will furnish a copy of a round trip ticket for my son/daughter.
Parent’s or guardian’s signature______
CERTIFICATION OF SPONSORING CLUB (To be completed by sponsoring club President or YE Chairperson)
Club name______City______
Have the applicant and family been fully informed of the program’s regulations and objectives?
Yes______No______
I certify that the applicant is fully qualified to participate in the Hawaii Lions International Youth Camp.
Signed______
Previous trips abroad/countries______
Have you participated in a Lions Youth Exchange Program? Yes______No______
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C. SOURCE FOR FINANCING TRIP
Please specify______
______
D.PARTICIPANTS AGREEMENT TO TERMS OF PROGRAM (Please read carefully)
If accepted to participate in the Hawaii Lions International Youth Camp 2015, District 50, Hawaii, I will abide with its policies and procedures. I fully understand that extended personal travel or leave of absence during the program is not permitted, even to visit close relatives or friends, unless written permission is included with this application. I understand that my participation in this program is not for the purpose of tourism, formal education or employment, and that I will not be allowed to have possession of nor consume tobacco/alcoholic products and to operate a motor vehicle during my visit in the host country. Any violation of the program, policies and regulations on my part, can, at the discretion of the IYC Chairperson, result in the immediate termination of my visit at my own expense.
Applicant’s signature______
INSURANCE/MEDICAL INDEMNITY
A.EMERGENCY MEDICAL TREATMENT AUTHORIZATION: In case of an emergency, I authorize the Hawaii Lions International Youth Camp, District 50, Hawaii officials or the host families to provide my son/daughter any necessary medical treatment prescribed by a doctor. I understand that any expense not covered by insurance or such medical treatment will be MY responsibility.
Parent’s or guardian’s signature______
B.INSURANCE: Applicant must obtain comprehensive medical, life, accident, personal property and liability insurance to cover his/her stay in the host country to be visited.
Name of Insurance Company______
Address of Insurance Company______
Policy Number______
Name______
Address______
C.INDEMNITY AGREEMENT: The parents or guardians are required to sign this form and return with the filed application to be considered for camp.
With the affixed signature, we the parents or guardians of ______permit him/her to travel and remain at an approved period living in Lions or Lion approved home.
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We agree to relieve any Lions Club member, host family, Lions Club, Hawaii Lions International Youth Camp Chairperson and/or the International Association of Lions Clubs of any financial or other responsibility, in the case of his/her illness or death, legal or moral responsibility and to indemnify them in respect to all expenses incurred. We also agree that the boy/girl will not be permitted to drive a motor vehicle, be in possession of nor consume tobacco/alcoholic products while a participant in the camp. The boy/girl will return to his/her home at the completion of the camp program. Should we send written permission regarding the housing and travel of our boy/girl to or following the Hawaii Lions International Youth Camp, we fully understand that Lion supervision will cease and that we will be fully responsible for the welfare of our boy/girl. We also agree that, should our boy/girl be returned home prior to the completion of the HLIYC due to camp rules violations, we will be liable for any additional financial costs this action may incur such as, but not limited to, air travel, housing, food, additional adult supervision, etc.
Father’s/Guardian’s signature______
Mother’s/Guardian’s signature______
Date______
ENDORSEMENT OF SPONSORING DISTRICT YEC
I have reviewed this application and give my full endorsement.
Signature______Date______
Address______
The Hawaii Lions International Youth Camp is a NON-SMOKING, NON-DRINKING CAMP. TOBACCO AND ALCOHOL PRODUCTS WILL NOT BE BROUGHT TO CAMP, PURCHASED NOR CONSUMED BY THE PARTICIPANTS of the Hawaii Lions International Youth Camp. If this rule is violated, the youth will be sent home. Furthermore, Hawaii State Law prohibits the sale of tobacco products and alcohol to youths under the age of twenty-on (21).
We agree that the boy/girl will be returned to his/her home country if the above rules are violated.
Father’s/Guardian’s signature______Date______
Mother’s/Guardian’s signature______Date______
Youth’s signature______Date______
MAHALO! Please return to:
Cynthia Chun, Chairperson Hawaii Lions International Youth Camp 2016 5634 Kanau St. Honolulu, Hawaii 96821
Home phone:1-808-373-9443 Mobile phone: 1-808-741-9443 Email:
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