PROGRAM PERTUKARAN PELAJAR DAN JARINGAN PENDIDIKAN ANTARABANGSA 2016 Sila Tanda Program yang anda ingin sertai; Program Ke Jepun Siri ( ) Program Ke Korea Siri ( ) London Siri ( ) Australia Siri ( ) Europe Siri ( ) I MAKLUMAT PERIBADI Nama ( SEPERTI DI PASPORT / HURUF BESAR ) Alamat Surat menyurat GAMBAR No Kad Pengenalan: Passport No : Warganegara No. Telefon Rumah/tel bimbit Tarikh Lahir Umur Agama Bangsa Nama Sekolah/Tingkatan Alamat Sekolah / No. Telefon II LATAR BELAKANG PENDIDIKAN Nama Sekolah Pangkat Tahun
III KEMAHIRAN BAHASA Bahasa Tulisan Percakapan IV LATAR BELAKANG AKTIVITI LUAR Senarai aktiviti Ko-kurikulum yang di sertai Jangka waktu Penglibatan Pengetahuan / Kemahiran Istimewa ( Kraf tangan, Bermain muzik, tarian dll ) Hobi Maklumat Terperinci keahlian dalam kelab, Persatuan atau pertubuhan Maklumat terperinci mengenai penglibatan lepas dalam Program pertukaran pelajar luar negeri, seminar atau lawatan sambil belajar ( jika ada )
V LATAR BELAKANG KELUARGA Nama Hubungan Umur Pekerjaan VI MAKLUMAT LAIN Apakah yang anda dapat sumbangkan jika terpilih menyertai program ini? Apakah yang anda harap / belajar apabila selesai menyertai program ini? Maklumat kesihatan ( Penyakit / Alahan )
VII ORANG YANG PERLU DIHUBUNGI JIKA BERLAKU KECEMASAN Nama Hubungan No. Telefon No. Fax E-mail VIII PENGAKUAN Saya dengan ini mengaku bahawa segala maklumat yang diberikan di atas adalah benar dan betul sepanjang pengetahuan saya dan sedia disingkirkan serta merta apabila terpilih jika terdapat sebarang kenyataan palsu atau yang tidak benar. Jika terpilih, saya setuju mematuhi segala peraturan yang telah di tetapkan oleh pihak Penganjur. -------------------------- ----------------------------- Tandatangan Peserta Tarikh
Hiroshima International Club Malaysia Transnational Exchange School Program MEDICAL RELEASE AUTHORIZATION WE, as parents of the undersigned student, do hereby authorize Hiroshima International Club Malaysia, the Coordinators concerning with this program and the host parents to act as agents of the undersigned parents to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment or hospital care which is deemed advisable by and is rendered under the general supervisions of any licensed physician or surgeon, whether such treatment or diagnosis is rendered at the clinic of said physician or surgeon or at a hospital. It is understood this authorization is not given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agents to give specific consent to any and all such diagnoses, treatment or hospital care which the aforementioned physician or surgeon in the exercise of his/her best judgment may deem advisable. This authorization shall be valid for the entire duration of the Hiroshima International Club Malaysia program in which the student is participating. Parent s Signature or Legal guardian Name: I/C : TEL NO : Date: Month / Day / Year Student s Signature Name : I/C : Date: Month / Day / Year
Hiroshima International Club Malaysia Transnational Exchange School Program TERM & CONDITIONS Below are the Hiroshima International Club Malaysia s terms of participation. Please read carefully and sign your name after you fully understand and agree to comply with these rules. 1. Hiroshima International Club Malaysia Transnational Exchange students must abide by the laws of Malaysia and by the rules of the school that they attend. 2. Students must always be aware of their responsibilities as an exchange student and make a determined effort in programmed. Students who are expelled from the program due to poor behavior will be sent home at their own expense. 3. Students cannot change host families or schools at will. 4. Students are expected to respect their host family. The most important things are to try to create a good relationship and communicate with host family members. The students will become one of the family members. Students must obey host family rules, for example curfews and household chores. Students may not have guests in the host family s home without their host parent s permission. 5. Students are not permitted to talk about the host family s private affairs to others. 6. Students must show respect for the officer from Ministry of Education Malaysia, Hiroshima International Club Malaysia coordinators (staff members), and the regional representative of Hiroshima International Club Malaysia and obey their instructions. 7. Students may not make any decisions or take any action that may change the nature or course of their life, i.e. getting married, changing religion, etc. 8. Students must not participate in any sexual contact or sexual activity that is inappropriate for minors. 9. Students are not permitted to go on trips alone or hitchhike. A trip with the host family or any other responsible adult is allowed if permission is given from the parents, the host parents and the Coordinator of Hiroshima International Club Malaysia and Ministry of Education Malaysia and an itinerary is submitted beforehand. Students are not allowed to travel while school is in session. 10. Students are not permitted to participate in sky diving, hang gliding, parachute jumping or any other dangerous activities. 11. Students are not permitted to drive any motor vehicles or obtain a driver s license while participating in the exchange program. 12. Students are not allowed to purchase or shoot guns of any type. 13. Students may not use drugs except those prescribed by a licensed physician or over the counter medications such as aspirin. 14. Students are not permitted to purchase or drink alcoholic beverages. Students are also not permitted to smoke. These activities are illegal for all persons under 18 years old. 15. Visits by members of the student s biological family from the home country of the exchange students cannot be arrowed. Visits by the friend of the exchange student from his/her home country cannot be arrowed. 16. Hiroshima International Club Malaysia Transnational Exchange students are expected to return to their native country on the date that the Hiroshima International Club Malaysia specifies. The coordinators of Hiroshima International Club Malaysia, your host family and the Ministry Of Education Malaysia will not be responsible for you after the end of the program.
17. Students are not allowed to have cell phones. The guidelines concerning the cell phone usage are set by Ministry of Education. I understand that I am responsible for obeying all Hiroshima International Club Malaysia Transnational Exchange program rules. I also understand that failure to abide by the above rules may result in my dismissal from the Hiroshima International Club Malaysia Transnational Exchange program, termination of my student visa, and I may be sent home at once at my own expense. Signature of Student Date: NAME I/C Signature of Parent Date: NAME I/C
Hiroshima International Club Malaysia Transnational Exchange School Program LIABILITY RELEASE Student s Name I hereby release the Hiroshima International Club Malaysia and all of their employees and field representatives, and host families from all liability, injury, damages or claims that I have incurred after the termination of the program. Further, I understand that I will not be covered by any insurance policy after the program has been terminated. The undersigned, as a student on the Hiroshima International Club Malaysia program, and the parents/legal guardians of the student on the program, renounce any claim against the Hiroshima International Club Malaysia, the coordinators, regional representative, teachers, counselors, schools where the students may be assigned, or any person intervening in the program, that might arise due to injury, damage, sickness, accident, delay, unusual circumstances or expenses due to strikes, war, atmospheric conditions, quarantine, government restrictions or regulations, or those derived from acts of omission or airlines, shipping companies, railroads, buses, transportation in general, hotels, restaurants or any other service given by companies, individuals or anyone related with the aforementioned. We understand that the student will be subject to the rules of the program, host family, school, teachers, and community where he/she will live. We also understand that Hiroshima International Club Malaysia reserve the right to terminate any student who participates in the program whose conduct may be considered detrimental or incompatible with the interest and security of the program. If this decision is ever taken, the student and his/her parents/legal guardian will have no right to any refunds. We accept the right for the Hiroshima International Club Malaysia to directly, or indirectly, change, cancel, or substitute, in emergencies or whenever normal circumstances change, those parts of the program whose alteration may be considered necessary. We also accept the right of the Hiroshima International Club Malaysia to change, before departure, the cost of the program to meet unexpected changes in airfares or the price of transportation in general, monetary devaluations, etc. We understand that should there be a geographic move of the students for any reason whatsoever, the cost of the transportation shall be borne by the student. We grant the permission of Hiroshima International Club Malaysia and permission to use in the future any photograph or any other type of material in which the student may appear, for promotion or publicity of the programs of Hiroshima International Club Malaysia. We also agree we will not make contact, directly or indirectly, with schools, regional representative, host families and friends for the purpose of sending future students to any of the said schools, the coordinators of Hiroshima International Club Malaysia, families and friends.
The student and natural parents/legal guardians agree to uphold the standards set by the Hiroshima International Club Malaysia, the school and the family with whom the student will live, for the duration of the program. The student also agrees to maintain friendly and respectful relations with teachers, classmates, and all family members, and to accept and follow rules of conduct imposed by said family and to participate in family life as much as possible. Signature of Parent Date: Or Guardian NAME I/C