Prospect-Barcelona Exchange Application 2013

Due Friday, May 25th
To apply for the Prospect-Barcelona Exchange 2012-13, 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. School ID Number*


  1. Overall GPA*


  1. Sex  *


  1. Street Address*


  1. City, State, Zip Code*


  1. Date of Birth (mm/dd/yy)*


  1. Home Phone xxx-xxx-xxxx*


  1. Student's Cell Number xxx-xxx-xxxx*


  1. Student's Email (school e-mail)*


  1. Father's Name*


  1. Father's Cell Number xxx-xxx-xxxx*


  1. Father's Work Number xxx-xxx-xxxx*


  1. Father's Email*


  1. Mother's Name*


  1. Mother's Cell Number xxx-xxx-xxxx*


  1. Mother's Work Number xxx-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 xxx-xxx-xxxx*


  1. Emergency Contact #1 Cell Phone xxx-xxx-xxxx*


  1. Emergency Contact #2 Name*


  1. Emergency Contact #2 Relationship*


  1. Emergency Contact #2 Home Phone xxx-xxx-xxxx*


  1. Emergency Contact #2 Cell Phone xxx-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 Barcelona, 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 reciprocal home-stay exchange where you will house your correspondent during their visit to Mount Prospect and then you will live with a family in or near Barcelona?  *


  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-Barcelona Exchange.





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