St. Francis of Assisi’s EnglishPrimary School

Circular No. 91 of the Academic Year 2010-2011

AustraliaStudy Tour 2011 27-1-2011

Dear Parents/Guardians,

Thank you for joining the Australia Study Tour. In order to undergo the procedures of the event, all the selected participants should complete the Reply Slip below and return it back together with the following documents or information to Miss Tam Ka Ming. Please see the details as follows:

  1. Photocopy of the Passport
  2. Student Health Condition Survey Form ( See the Appendix I )
  3. Letter of Authorization ( See the Appendix II )
  4. The Home-stay Profile of NIC ( See the Appendix III )
  5. The Completed Application Form of the Insurance (See the Appendix IV )
  6. Others ( if necessary )

I would be most grateful if you could fill in the reply slip below and return it to Miss Tam Ka Ming on or before31-1-2011.

Yours sincerely,

Mr LAU Wai-ming

(Principal)

______

Reply Slip

AustraliaStudy Tour 2011

Date: ______

To: The Principal of St. Francis of Assisi’s EnglishPrimary School

I read in acknowledgement of the above notice in connection with the relevant arrangements made by the School.

*Remark: 1. The following personal details must be the same as the passport.

2. The expiry date of the passport should be SIX MONTHS after23-4-2011.

Name in Chinese / Name in
English / Sex / Expiry Date of
the Passport / Telephone No. / Emergency Telephone No. / Request for the Child Meal
Yes / No

Signature of parent/guardian:______

Name of parent / guardian:______

Name of Student:______

Class:______( )

Appendix I

Student Health Condition Survey Form

Australia Study Tour 2011

Dear Parents/Guardians,

Health Condition is considered to be very important issue for each individual student participating in the educational tour. You are required to complete the following survey for our reference.

Yours sincerely,

Mr LAU Wai-ming

(Principal)

------

Date : ______

Student Health Condition Survey Form

Student’s Name :______Sex :______

Class :______( ) Date of Birth:______

Name of Parent/Guardian:______Telephone for emergency:______

  1. Please indicate with X and details if your child has suffered the following disease:

Put ‘X’ (if any) / Name of Disease / State the age when the child was diagnosed with the Disease / Details of the
Diseases

Glucose 6-Phosphate Dehydrogenase Deficiency

Asthma
Epilepsy
Convulsion due to High Fever
Renal Disease
Heart Disease
Diabetes Mellitus
Hearing Impairment
Haemophilias
Anaemias
Other Blood Disease
Drug Allergy
Vaccine Allergy
Food Allergy
Other Allergy
Pulmonary Tuberculosis
Minor Operation
Major Operation
Other Disease (please specify):
  1. Please indicate below if your child is NOT suitable to attend any special activities including indoor or outdoor activities.

*Please also specify corresponding reasons.

______

  1. Please submit relevant doctor’s certificate for our information.

4. Other remarks (if any):______

I hereby declare that the above information is correct.

Parent’s/Guardian’s Signature : ______Name :______

Appendix II

The Letter of Authorization

Australia Study Tour 2011

Date :______

To : Principal of St. Francis of Assisi’s English Primary School

*Please complete every detail and delete the inappropriate words

I (Name :______) hereby authorize the teachers-in-charge of the Study Tour, Miss Tam Ka Ming, Mr Yuen Chun Tong, Miss Lee Pik Wah and Mr Chiu Kwan Kei to be the Guardians of my child ______in Class_____(Passport No. :______) during the Australia Study Tour on23rd April 2011– 2nd May 2011.

I would be very grateful if the above Authorized Guardians to help me take care of my child and fix the following arrangements in the Tour as below :

  1. To assist and lead my child to undergo all the formalities of the Hong Kong and Australia Immigration Department.
  2. To be the Authorized Guardians of my child and to take care of him/her when having indoor or outdoor activities during the Tour.
  3. If my child gets sick or injured in the Tour, I authorize the above Guardians to make necessary arrangements subject to the doctor’s consultations and pay for any consultation fees.

I have read the term and conditions stated above and agree to abide by :

I confirm that my child is fit for travel independently and able to participate in the tourprogram. He/She is also covered by the personal travel insurance.

Parent’s/Guardian’s Signature in Hong Kong :______Name :______

HKID No./Passport No.:______

Emergency Contact person and Telephone Number :

1)______

2)______

Appendix III

Ref: HMSTAYST.PRO

NUDGEE INTERNATIONAL COLLEGE

STUDENT HOMESTAY APPLICATION FORM

FAMILY NAME: ______

GIVEN NAME(s): ______

ADDRESS:______EMAIL: ______

(HOME COUNTRY)

______TELEPHONE:______

Nationality:______Sex:  Male  Female Date of birth:___/___/___

Length of homestay Commencement date of

required:______homestay: ___/___/___

Australian Contact: Name______Address ______Telephone Number ______Email:______

Please complete the boxes below with your family details:

Given Names / Birth date/Approx Age / Relationship / Occupation

Please indicate your hobbies or interests:

Rugby  Surfing  Art  Reading Watching movies

 Baseball  Swimming  Photography  Aerobics Listening to music

 Tennis  Sailing  Hiking  Dancing Scuba diving

 Golf  Basketball  Fishing  Soccer Martial Arts

 Travel  Cooking  Playing musical instruments

Please answer the following:-

Your English speaking ability is:  very good  good  fair  poor

Would you prefer a family with children?  yes  no  either

Do you have any objections to pets?  yes  no

Do you smoke?  yes no  yes, but I will smoke outside

(Most Australian families do not allow smoking in the house)

Do you drink alcohol? yes no

Are you allergic to any food? Please specify______

Do you have any food dislikes?______

Do you have any health problems? Any allergies? Please specify______

______

Do you take any medicine?  yes no

If yes, please give details:______

Do you like animals: Yes/No Please specify by circling: Cat Dog Bird Fish

How would you describe yourself?

 sociable positive  co-operative  high achiever  shy

 curious cheerful  emotional  affectionate

 nervous quiet  serious other______

Please indicate your religion:______

Have you ever lived away from home before?  yes  no

Your Australian family is looking forward to meeting you. Please write them a brief letter in English, describing your family, your activities and your reasons for wanting to travel to Australia and live with a family.

______

Who could NIC contact in case of an emergency?______

It is suggested that students arrange appropriate personal and health insurances to cover unforeseen circumstances.

I acknowledge that the NUDGEE INTERNATIONAL COLLEGE(NIC) accepts no responsibility in relation to homestay placements and that I accept all risks in that regard. I understand that one week’s notice (or one week’s payment in lieu) must be given to either NIC or Homestay Family prior to departure from homestay earlier than the agreed date. NIC will endeavour to rearrange homestay in appropriate circumstances.

Student’s Signature:...... Date:......

If under 18 years of age:

I hereby accept that the assigned group leader, host family member or local co-ordinator may act as responsible guardian for my son/daughter and may decide on emergency medical treatment without personal liability.

Parent’s Signature:...... Date:......

OFFICE USE ONLY
Appointments / Placement/s

Appendix IV

Appendix IV

聖方濟各英文小學

二零一零至二零一一年度通告第九十一號

澳洲遊學團2011 27-1-2011

敬啟者﹕多謝 貴子弟參與本校舉辦之「澳洲遊學團」。現致函 貴家長填寫個人資料，以便辦理登機程序事宜。請各家長填妥回條，並連同下列所需文件於交回譚嘉明主任為荷。有關資料，臚列如下：

  1. 有效旅遊證件副本（護照）
  2. 學生健康狀況調查表(見附件一)
  3. 授權書(見附件二 )
  4. NIC寄住家庭申請表(見英文版附件三)
  5. 已填妥保險申請表 (見附件四)

7. 其他資料 ( 如有需要)

上述事項，敬請垂注；並請填妥下列回條連同上述所須文件於一月三十一日前交回譚嘉明主任為荷。

此致

貴家長台照

校長：劉偉明 謹啟

______

回 條

澳洲遊學團2011

敬覆者：本人經閱 貴校二零一零至二零一一年度通告第九十一號，並知悉 貴

校有關之安排。現附上有關參加遊學團學生之個人資料如下：

備註：填寫資料須與旅遊證件資料相符，注意旅遊證件有效期須在出發後六個月內有效。

學生中文全名 / 學生英文全名 / 性別 / 旅遊證件到期日
(年/月/日) / 聯絡電話 / 緊急聯絡電話 / 是否要求兒童餐?
是/否

此覆

聖方濟各英文小學校長

家長簽署：______

學生姓名：______

班 別：______

日 期：______

附件一

澳洲遊學團2011

學生健康狀況調查表

敬啟者: 參加澳洲教育考察團的學生，均須填妥以下健康狀況調查表，以供老師作參考之用。

此致

貴家長台照

校長 : 劉偉明 謹啟

------

澳洲遊學團2011

學童健康狀況調查表

學生姓名：______性 別：______

班 級：______出生日期：______

家長/監護人姓名：______聯絡電話：______

1. 如學生曾患有以下疾病，請在適當的方格內註明「X」記號及列出詳情：

患病時年齡 / 疾病資料
六磷酸葡萄糖脫氫酶素缺乏症
哮喘
羊癎
高熱引致抽搐
腎病
心臟病
糖尿病
聽覺不健全
血友病
貧血
其他血病
藥物敏感
疫苗敏感
食物敏感
其他敏感
肺結核
小手術
大手術
其他
  1. 倘認為學生不適宜參加任何類型的活動，請具體說明：

______

  1. 請提交醫生證明書供校方參考。

4. 其他補充資料：

______

本人特此聲明，就本人所知，上述表格內之一切資料，全屬真確。

日期：______家長/監護人簽署：______

家長/監護人姓名：______

附件(二)

澳洲遊學團2011

授權書

致聖方濟各英文小學校長

本人授權譚嘉明主任、阮椿堂主任、李碧華老師及趙均基老師作為小* 兒 / 女 ______(護照號碼 : ) 於2011年4月23至5月2日澳洲遊學團期間之監護人。

本人願意授權以上監護人作以下安排 :

  1. 帶領及協助小 * 兒 / 女 於香港及澳洲出入境。
  2. 於澳洲遊學團期間所有校內及校外活動作為小 * 兒 / 女之監護人，及在考察團期間照顧小* 兒 / 女。
  3. 若小* 兒 / 女在參加澳洲遊學團期間患病或受傷，本人願意授權學校及監護人依照現場醫生指示處理，並會負責所有費用。

*請將不適用刪除

本人已詳閱上述條款、安排及確認小* 兒 / 女之身體狀況良好，適合獨立自行參與上述之考察團；並已購買旅遊保險。

香港之家長 / 監護人

簽署 : ______

家長姓名 : ______

香港身份證號碼 : ______

日期 : ______

緊急聯絡人姓名及電話 : 1) ______

2) ______

Appendix III

Ref: HMSTAYST.PRO

NUDGEEINTERNATIONALCOLLEGE

STUDENT HOMESTAY APPLICATION FORM

FAMILY NAME: ______

GIVEN NAME(s): ______

ADDRESS:______EMAIL: ______

(HOME COUNTRY)

______TELEPHONE:______

Nationality:______Sex:  Male  Female Date of birth:___/___/___

Length of homestay Commencement date of

required:______homestay: ___/___/___

Australian Contact: Name______Address ______Telephone Number ______Email:______

Please complete the boxes below with your family details:

Given Names / Birth date/Approx Age / Relationship / Occupation

Please indicate your hobbies or interests:

Rugby  Surfing  Art  Reading Watching movies

 Baseball  Swimming  Photography  Aerobics Listening to music

 Tennis  Sailing  Hiking  Dancing Scuba diving

 Golf  Basketball  Fishing  Soccer Martial Arts

 Travel  Cooking  Playing musical instruments

Please answer the following:-

Your English speaking ability is:  very good  good  fair  poor

Would you prefer a family with children?  yes  no  either

Do you have any objections to pets?  yes  no

Do you smoke?  yes no  yes, but I will smoke outside

(Most Australian families do not allow smoking in the house)

Do you drink alcohol? yes no

Are you allergic to any food? Please specify______

Do you have any food dislikes?______

Do you have any health problems? Any allergies? Please specify______

______

Do you take any medicine?  yes no

If yes, please give details:______

Do you like animals: Yes/No Please specify by circling: Cat Dog Bird Fish

How would you describe yourself?

 sociable  positive  co-operative  high achiever  shy

 curious  cheerful  emotional  affectionate

 nervous quiet  serious other______

Please indicate your religion:______

Have you ever lived away from home before?  yes  no

Your Australian family is looking forward to meeting you. Please write them a brief letter in English, describing your family, your activities and your reasons for wanting to travel to Australia and live with a family.

______

Who could NIC contact in case of an emergency?______

It is suggested that students arrange appropriate personal and health insurances to cover unforeseen circumstances.

I acknowledge that the NUDGEE INTERNATIONAL COLLEGE(NIC) accepts no responsibility in relation to homestay placements and that I accept all risks in that regard. I understand that one week’s notice (or one week’s payment in lieu) must be given to either NIC or Homestay Family prior to departure from homestay earlier than the agreed date. NIC will endeavour to rearrange homestay in appropriate circumstances.

Student’s Signature:...... Date:......

If under 18 years of age:

I hereby accept that the assigned group leader, host family member or local co-ordinator may act as responsible guardian for my son/daughter and may decide on emergency medical treatment without personal liability.

Parent’s Signature:...... Date:......

OFFICE USE ONLY
Appointments / Placement/s

附件(四)

附件(四)