Prospect-Madrid Exchange Application

Due __________
To apply for the Prospect-Madrid Exchange 2012, please fill out the application below and turn in, to your teacher, a one page typed explanation of why you would like to participate this year. Information about how to request teacher recommendations will be passed along at a later date.


A red asterisk (*) indicates required questions.

  1. Last Name*


  1. First Name*


  1. Current Year in School*


  1. School ID Number*


  1. Overall GPA*


  1. Sex  *


  1. Street Address*


  1. City, State, Zip Code*


  1. Date of Birth (Month/Day/Year)*


  1. Home Phone*


  1. Student's Cell Number*


  1. Student's Email*


  1. Father's Name*


  1. Father's Cell Number*


  1. Father's Work Number*


  1. Father's Email*


  1. Mother's Name*


  1. Mother's Cell Number*


  1. Mother's Work Number*


  1. Mother's Email*


  1. Number of Siblings*


  1. Preference of Exchange Correspondent  *


  1. Emergency Contact #1 Name*


  1. Emergency Contact #1 Relationship*


  1. Emergency Contact #1 Home Phone*


  1. Emergency Contact #1 Cell Phone*


  1. Emergency Contact #2 Name*


  1. Emergency Contact #2 Relationship*


  1. Emergency Contact #2 Home Phone*


  1. Emergency Contact #2 Cell Phone*


  1. Allergies or Fear of Pets?  *


  1. Vegetarian?  *


  1. List Pets in Your Home*


  1. Please List Other Allergies (Food or Medication)*


  1. Current Physician's Name*


  1. Current Physician's Phone Number*


  1. Any medical conditions of which we should be aware?*


  1. Are you currently taking medication?*


  1. As a student participant in this educational tour to Madrid, Spain to take place over spring break next year, do you promise to conduct yourself in accordance with all rules and regulations related to student conduct as set forth by the Board of Education of Township High School District 214?   *


  1. Do you further agree that you are subject to the disciplinary authority of the Board and employees in connection with any misconduct during the trip/tour?  *


  1. Do you understand that the possession or use of any controlled substance including, but not limited to, alcohol, illegal drugs, and tobacco is prohibited during the trip/tour?  *


  1. Do you understand that you may be subject to disciplinary consequences which may include suspension, expulsion, and / or requirement to return home at the expense of your parents before the conclusion of the trip?  *


  1. Do you understand that the Board of Education reserves the right at any time prior to or during the tour to make cancellations or changes in the interest of the group?  *


  1. Do you understand that this is a home-stay exchange where you will live with a family of a high school student in Madrid? (We are currently working on getting this exchange to be reciprocal; you would then be expected to house your correspondent during their visit to Mount Prospect)* *


  1. Anything else you think would be helpful? *


  1. Please also submit a one page typed explanation about why you would like to participate in the Prospect-Madrid Exchange.





Prospect
Spanish / French Teacher
Prospect High School
Mt. Prospect, IL