Ivanovo Exchange 2017
Information, Application and Consent
About the Exchange
Staffordshire Council of Voluntary Youth Services and YMCA Ivanovo have been developing their international partnership since 2011 as one strand of a civic link between the 2 areas which has been running for over 15 years.
Following involvement in official civic visits in 2012, the first youth delegation took place in October 2013 with 8 Staffordshire young people who were regularly involved in local volunteering. Since then an exchange has happened each year, and in 2017 it is our turn to recruit and send a group of local young people involved in volunteering.
Objectives of the Youth Exchange
1) Opportunity for British and Russian young people to learn more about a different culture, dispel myths and connect through fun and friendship. This includes the opportunity to live with a host family for the week.
2) To meet with the Mayor of Ivanovo, to pass civic greetings from Staffordshire and to demonstrate the strength and value of the youth exchange.
3) To understand the volunteering and social action opportunities that exist for young people in Russia and the benefits these can have to the individual and the community.
4) To get involved in small social projects to enable the communities of Ivanovo and Staffordshire to see the wider benefit of this type of international exchange programme.
5) For young people to discuss the international partnership and explore their ideas for ongoing development in future.
6) To optimise the opportunity afforded by a week in Staffordshire and to visit places of significant interest.
Background
Ivanovo is a city of around 400,000 people, with 9 universities. It is famous for its linen trade and being a place where women outnumber men by 2 to 1. Ivanovo is approximately 300 KM north east from Moscow.
The YMCA in Ivanovo is 22 years old, and gives local young people opportunities to give something back to their city. Programmes include summer camps for young people and families, young leader training, drug prevention, supporting older people with use of IT, fundraising and international exchanges.
Financial Information
SCVYS is able to pay for the following elements of the trip:
• Flight costs for all participants
• Insurance for the group
• Transport costs to and from the relevant UK airport
Ivanovo YMCA will cover the following costs whilst in Russia:
· Transport
· Living costs (food, accommodation etc.)
Participants are asked to contribute:
• Cost of getting / renewing a passport if required (In order to apply for a Russian Visa you will need at least 6 months validity from the date of travel)– (Approx. - £72.50-85)
• Cost of Russian visa and travel to London to personally evidence and verify their application
(Approx. - £130)
• Spending money (Suggested £50-75)
• Small thank you gift for your host family (Suggest £5-10)
Full information will be provided at a parent and participant meeting in July.
Application Information
The application process is not designed to exclude any potential applicant. Rather the intention is to ensure that parents/ guardians, youth leaders and organisers are fully aware of the details of the programme, any special risks or concerns and any special supports that may need to be put in place. The top priority is to ensure the safety of all participants at all times and your full co-operation is essential in this regard.
The information contained in this Parental / Guardian Consent form will be kept confidential and only shared with personnel on a “need to know basis”. If you do not fully understand any of the following questions, need further information or wish to discuss any of your answers it is most important that you contact the organiser of the exchange visit immediately on the contact details at the end of this document.
Application Form – Ivanovo Exchange 2017
October 2017
To be completed by the applicant.
Closing date for applications is 30th June 2017.
Participant Name: / Date of Birth:Youth Group:
Why would you like to take part in the Ivanovo exchange?
What do you hope to gain by taking part?
What skills and experiences could you bring to the exchange?
Are you involved in any local community activities?
For example: Youth Club, Scouts, Guides, Church Group, Sports Club, Drama
Signature of Participant:
Participant Registration and Consent Form
This remainder of this form needs to be completed by a parent or carer of the applicant unless they are living independently. If living independently or over 18 the young person can sign the form themselves.
This does not guarantee a place on the exchange, or affect a young person’s application – only the application form will be considered when allocating places.
Description of activity / Ivanovo Exchange 2017Date from / Exact date TBC – Between 20th and 22nd October 2017
Date to / Exact date TBC – Between 27th and 29th October 2017
Leader / Simon Protano
A: Applicants Personal Information
Forename(s)Surname
Gender / Male o Female o
Date of Birth
Address
Telephone
Email Address
Passport expiry date / (Expiry date can be no earlier than 1st May 2018)
If you will be applying for a new passport, or renewing a current passport please tick this box. o
If you are over 18 or living independently please tick this box. o
B: Additional Information
1. Dietary Requirements, this should include details of any food allergies and details of particular dietary needs, including religious food needs.
2. Medical Requirements, this should include details of medical conditions, medication taken and any non-food related allergies
3. Religious Requirements, this should be used to give details of particular religious needs, not identified in the dietary section.
4. Additional Requirements, this should be used at the discretion of the individual to include any additional information that might be helpful for leaders
C: Doctors name and surgery details
Doctors nameAddress of surgery
Telephone
D: Emergency contacts (parent/guardian/next of kin)
Please provide two emergency contacts.
NameRelationship to participant
Home Address
Contact telephone
(home, work, mobile)
Name
Relationship to participant
Home Address
Contact telephone
(home, work, mobile)
E: Photograph and Video Consent
Video & photographs will be taken throughout the exchange and could be used by SCVYS for promotional purposes, please sign below if you agree to the taking and use of photographic images for these purposes.
SignedF: Declaration
1. I confirm that I have read the details provided to me about the above youth exchange visit.
2. I confirm that the details provided are accurate at the time of completing the forms.
3. I hereby give consent to my son/daughter to take part in the above mentioned youth exchange and to his / her participation in the activities described.
4. I agree that he/she will be under the authority of, and responsible to, the youth exchange leaders from SCVYS and Ivanovo YMCA and to the host family.
5. I am aware of the rules of the exchange visit and accept the rules of the visit in relation to alcohol, drugs and sexual activity.
6. I accept that it may be necessary to send my son/daughter home in the following circumstances:
a) If they breach the rules of the exchange
b) If their behaviour is deemed to be inappropriate or offensive to the host community or if it endangers themselves or other people or causes damage to any property
c) If medical reasons require that they need to be sent home.
In cases a and b above that may be at my own responsibility and cost
7. I undertake to inform the co-ordinators as soon as possible of any change in medical circumstances between the date signed and the commencement of the exchange visit.
8. I agree to my son/daughter receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.
9. I understand the extent and limitations of the insurance cover provided.
Print name and signRelationship to participant
Date
Closing date for applications is Friday 30th June 2017
Please return this form to SCVYS, 42a, Eastgate Street, Stafford, ST16 2LY or
email to
If you have any queries about the project or the application process, please contact the office on 01785 240378 or by email on