Registration Form Youth Ambassador Trip to Japan "*" indicates required fields Step 1 of 4 25% Student InformationName* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Current Grade Level* 9 10 11 12 Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* School Activities*Clubs, athletic teams, etc. Other Memberships and Activities*Outside of school groups Have you hosted students from Isesaki?* Yes No Year Hosted* Isesaki Student Name* Hobbies* Why do you want to travel to Japan as an ambassador?*Student Health InformationPhysician Name* Hospital Name* Hospital Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician Phone*Physician Email Health Concerns to Inform Host Families*Allergies, etc. Parent/Guardian InformationPrimary Parent/Guardian Name* First Last I am interested in serving as a parent chaperone*When parent chaperone space is available, we will contact you. The trip cost for a parent chaperone is the same as the student cost. Yes No Relationship to Student* Address is the same as student's* Yes No Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I will provide my*(check all that apply) Home Phone Cell Phone Work Phone Home Phone*Cell Phone*Work Phone*Email* Secondary Parent/Guardian Name First Last I am interested in serving as a parent chaperoneWhen parent chaperone space is available, we will contact you. The trip cost for a parent chaperone is the same as the student cost. Yes No Relationship to Student Address is the same as student's Yes No Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail Consent FormConsenting Parent(s)/Guardian(s) Name(s)* Student Name* Consent*I, consenting parent(s)/guardian(s) listed above, have received the trip payment schedule and agree to make payments accordingly. I understand that failure to make payments on time may cause withdrawal from the trip, without refund of the previously paid amount. Also, I have read the cancellation policy and I will abide by the policy. I certify that I have been fully informed concerning the nature and extent of the trip, and I understand that there may be an increased risk of physical injury. I hereby consent to allow my son/daughter/dependent to participate in the trip. I authorize and consent in advance to any necessary medical treatment which may be required by my child/dependent (named above) while he/she is participating in the trip and agree to be responsible for the cost of such medical treatment. I hereby release Springfield Sister Cities Association and its staff and volunteer members from any and all claims, causes of action or damages resulting from: (1) any decisions made by the association’s staff and volunteer members to obtain medical treatment for my child/dependent in conjunction with the activity; or, (2) the treatment/medical procedures provided by the medical provider. I authorize and consent in advance to any additional travel costs such as airfare and hotel due to inclement weather conditions and other natural disasters and agree to be responsible for the cost of such travel arrangement. I hereby release Springfield Sister Cities Association and its staff and volunteer members from any and all claims, causes of action or damages resulting from weather related delay or natural disaster. I understand and agree that if a student violates laws and/or faces a serious disciplinary issue, the association can terminate the student from the student delegation before and during the trip. If this happens while the student is in Japan, the student will be asked to discontinue the trip with the delegation and follow an alternate trip itinerary under the supervision of the trip chaperon or city officials in Japan. I agree to the consent policy.Today's Date* MM slash DD slash YYYY PassportPlease upload a copy of the student's passportYou can provide this at a later date. It is due by Monday, January 1, 2024. If you have trouble uploading, please e-mail to asaner@springfieldmo.gov.Max. file size: 512 MB.PaymentThe registration fee is $200 and is due by Sunday, April 30, 2023. You may mail a check payable to "SSCA" to SSCA Student Ambassador Trip, 2400 S. Scenic Ave., Springfield, MO 65807. You may also pay now with a card (includes addition of $6.28 in processing fees). Subsequent payments are $330 if paying by check or $340.16 if paying by card. They are due on the 30th of each month through April 2024. Pay in full by Sunday, April 30, 2023 to save $30 if paying by check or $34.24 if paying by card. Payment Method* I will send a check for $200 I will send a check for $3,800 I will pay now with a card Payment Amount* Registration Fee ($200+$6.28) Pay in Full ($3,800+$113.80) Credit Card* Cardholder Name Card Details CAPTCHA
