Prospect-Verona Exchange Application

Due May 23, 2011
To apply for the Prospect-Verona Exchange 2011-12, 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 (9th, 10th, or 11th)*


  1. School ID Number*


  1. Overall GPA*


  1. Sex  *


  1. Will you be continuing through Italian AP?  *


  1. Street Address*


  1. City, State, Zip Code*


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


  1. Home Phone (area code) XXX-XXXX*


  1. Student's Cell Number (area code) XXX-XXXX*


  1. Student's Email*


  1. Father's Name*


  1. Father's Cell Number (area code) XXX-XXXX*


  1. Father's Work Number (area code) XXX-XXXX*


  1. Father's Email*


  1. Mother's Name*


  1. Mother's Cell Number(area code) XXX-XXXX*


  1. Mother's Work Number (area code) XXX-XXXX*


  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 (area code) XXX-XXXX*


  1. Emergency Contact #1 Cell Phone (area code) XXX-XXXX*


  1. Emergency Contact #2 Name*


  1. Emergency Contact #2 Relationship*


  1. Emergency Contact #2 Home Phone (area code) XXX-XXXX*


  1. Emergency Contact #2 Cell Phone (area code) XXX-XXXX*


  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 Verona, Italy 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 reciprocal home-stay exchange where you will live with a family in or near Verona and 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 on paper to your teacher about why you would like to participate in the Prospect-Verona


  1. Briefly describe your family/home life:


  1. What arrangements will you make for your Italian partner during sports, band, or other commitments in which he or she may not be able to participate?


  1. Why do you feel you should be selected for this exchange?


  1. Parent Response: Briefly describe how your family is prepared to host an Italian young adult in your home for two weeks.


  1. List the activities and/or sports in which you are involved in the fall:


  1. List your interests and hobbies and how you spend your free time outside of school and school sponsored activites:


  1. Will you, or someone in your family, be able to "take your Italian to work" one day as part of a project required by the Verona Chamber of Commerce?
    Yes
    No


  1. Is smoking allowed in your home?
    Yes
    No





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