Centre du Sport et de la Jeunesse de Corse
Chemin de la sposata
20090 AJACCIO
YOUTH EXCHANGE CONTACT
Mathilda Olive +33(0)6 02 09 04 37
Contact CSJC
/
Welcome Office : +33(0) 495 10 65 10
APPLICATION FORM
YOUTH EXCHANGE TITLE :
DATES :
VENUE :
PLEASE NOTE
PARTICIPATION WILL BE VALID
ONLY AFTER HAVING FULFILLED THE PRESENT FILE
PARTICIPANT’S PROFILE
FIRST, LAST NAME
DATE OF BIRTH + AGE:
FULL POSTAL ADRESS :
EMAIL ADRESS :
PHONE NUMBER (WITH DIAL CODE) :
FACEBOOK NAME :
PASSEPORT NUMBER :
T-SHIRT SIZE :
MOTIVATIONS DU PARTICIPANT
Please answer each question, give true answers, specific to you. Consider, that based on your answers we can develop the program in a way that serves your needs. General answers do not support.
WHAT MAKES YOU INTERESTED IN THIS EXCHANGE?
WHAT DO YOU WANT TO LEARN DURING THE EXCHANGE?
DO YOU HAVE ANYTHING TO SAY REGARDING THE TOPIC OF THE EXCHANGE?
TARIF DE L’ÉCHANGE
The project is in part subsidizedby the Erasmus + program and CSJC. The accommodation, food, activities and coaching are provided to participants, and CSJC request a symbolic financial contribution to participants.
We kindly ask you to come with cash of the following amount :
Youth exchanges held in Corsica / 15€Please note that this price includes all expenses of the participant (accommodation, restaurants (beside beverages), activities) Note that if the participant cancels the participation meanwhile financial expenses were initiated by the CSJC (plane ticket for example), the participant will be asked to pay all the expenses incurred by the CSJC.
PARENTAL AUTHORIZATION
I, Mr or Mrs ......
(name of theparticipant’s legal representative)
Being the legal representative of ......
(name of the participant)
certify to give him/her permission to :
-Participate in activities organized by the Centre du Sport et de la Jeunesse de Corse
-Take place in a CSJC vehicle to go for outdoor activities
IMAGE RIGHT
(PLEASE SCRATCH THIS PART IF YOU DON’T WANT TO BE IN MEDIA DOCUMENTS)
Any natural person has the exclusive right on their image and the use made of it. This right includes not only the image but also all the constituent elements of the personality (voice, silhouette...).
Every athlete, every participant attending the CSJC establishment accepts films, photographies or other identifications of themselves taken during workouts or trainings and could be used by partner structures as institutional promotion. It allows these structures to exploit by any means. The documents used must however have been taken or acquired during the period when the athlete or the student was enrolled in CSJC.
The CSJC can freely use these images on all of its information and communication supports.
I declare on my honor, the accuracy of the information above.
TRAVEL AND CANCELLATION
I have taken note that IF the CSJC committed financial expense of participants' travel tickets. I confirm that if I withdraw while a financial outlay by the CSJC was committed (type of plane ticket ...) I will pay my sums already committed by the CSJC.
I hereby declare the accuracy of the information above.
PLACE :DATE :
SIGNATURE
PROFIL MÉDICAL
Please answer to each question with exactitude, this will help us to know you more and adapt activities regarding your and other participants’ profiles.
CAN YOU SWIM MINIMUM 50 METERS ALONE?YES / NO
DO YOU PRACTICE SPORT REGULARILY?YES / NO
IF YES, WHAT SPORT?
DO YOU HAVE THE FOLLOWING CONDITIONS :
Yes No / Yes No1. Allergies / / 6. Joint problems (neck, back, shoulders, knees, ankles, other...) /
2. Regular medication / / 7. Other disease or symptom (diabetes, asthma, headache, epilepsy, fainting…) /
3. Hospitalized in the last 2 years / / 8. Special diets and need (vegetarian, religious diets, food allergies...) /
4. Heart disease or in close family / / 9. For women: pregnant? /
5. High blood pressure / / 10. Do you have mobility issue and/or a specific disability ? /
PLEASE NOTE BELOW THE REASONS WHY YOU ANSWERED "YES" TO ONE OR MORE OF THE ABOVE QUESTIONS. CAN YOU EXPLAIN THE SYMPTOMS AND / OR RESTRICTIONS?
PLEASE NOTE OTHER RECOMMENDATIONS PARENTING / OTHER REPORTABLE.
EMERGENCY CONTACT
NAME, SURNAME:
RELATION TO PARTICIPANT:
PHONE NUMBER (with dial code):
OTHER EMERGENCY CONTACT :
In case of emergencyI authorize the responsible to proceed with any medical emergency response
PLACE ...... DATE ......
SIGNATURE
INSURANCES
The Center of Youth and Sports provides insurance to the French participants or participants who stay in the establishment. Note that it is the partner organization must also ensure their participants.
TRAVEL INSURANCE
Werecommendthatyou have travelinsurance.
PERSONAL INSURANCE
Weaskyou to give us a copy of the personalinsurance of the participant.
WestronglyrecommendthatyoumakeyourownEuropeanHealthInsuranceCard.
It is a free cardthatgivesyouaccess to medicallynecessary, state-providedhealthcareduring a temporarystay in any of the 28 EU countries, Iceland, Lichtenstein, Norway and Switzerland,under the same conditions and at the samecost (free in some countries) as people insured inthat country.
More info:
SUMMARY OF NEEDED DOCUMENTS
I, the undersigned ...... Certifies on honor :
Have accurately completed all the required parts:
Profileand motivation of the participant
Medical profile
Contact in case of emergency
Have signed the compulsory parts:
For underaged participants, parental authorization
Agreement on cancellation
Authorized officials to carry out any emergency response
Have joined to the present file the following documents:
Personal Insurance copy
Participation fee (can be taken to the first day of exchange)
“Readandapproved”
Date :Place :
SIGNATURE