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PREFERRED YOUTH EXCHANGE ALTERNATIVESTo:1st Country (& Camp) preference2nd Country (& Camp) preference3rd Country (& Camp) preference First Name:E-mail:Street address: Field of study:Career objective:Hobbies & Other interests:Knowledge of English: Good Other languages spoken:Mobile: Yes If yes, where and when?Name of Insurance Company: Policy no:State of health, in general:Special medication:-Medical/Religious/Other dietary requirements:Physical handicaps if any: Blood group: Vegetarian? Any other point to be noticed: E-mail: Phone:&"Family Doctor", if you have one:  Name:No Yes Lions member Mother's occupation:  Mother's name: " Father or Guardian's occupation:  Father or Guardian's name: Phone: Mobile phone:  Fax: Lions Club: District:  Phone: E-mail:  Fax: Address:5Basis of financing of the exchange: By applicant:  By family:  By sponsor club: OthersName:Primary Phone:.Possible dates for exchange From:Family stay and CampFamily stay onlyII. APPLICANTs BASIC DATA Family Name:The Applicant prefers (X): Country: Postal code: Town:State: Phone(home): /2Applicants YES Code (Year / District / Number):4Applicant's destination (Country/State/(M)District): Nationality:Allergies, if yes, specify: T-shirt size (S, M, L, XL, XXL): Fair None Male (M) or Female (F) /PHOTO (To be attached on the final copies only)EHave you previously participated in a Lions Youth Exchange Program? Do you smoke?d Applicant's Health, Medical and Dietary Data (Add and specify in the additional data as necessary) . Religion:?IV. APPLICANT'S ADDITIONAL DATA (as applicable and available) ! , Additional Health, Medical and Dietary Data5Are you capable to participate in sport activities ? V. APPLICANT'S FAMILY DATAVI. RESPONSIBLE LIONS CLUB DATADVIII. AGREEMENT AND COMMITMENT BY APPLICANT (Please read carefully)- XI. ALL OTHER INFORMATIONX. SIGNATURESDate:Instructions: The Applicant, his/her parents, and the responsible Lions shall complete all appropriate sections of this form. Mobile: .IX. INDEMNITY AGREEMENT BY PARENT OR GUARDIAN Are you a LeoYes(X)Applicant name signatureParents / Guardians nameClub representative name/This form must first be completed and forwarded electronically. Duly signed paper copies with the attachments must be forwarded as advised separately. For privacy reasons all data can only be used for Youth Exchange purposes and will not be disclosed outside of the Youth Exchange without your consent.Compulsory attachments to this application are 3 photographs self and a letter to "Dear Host Family". One or more "family photographs" and a copy of the Applicant's passport or an equivalent identification document, as required for the applied countries, are recommended. Date of birth (dd/mm/yyyy): Passport Nr.Passport: place of issuePassport: valid untilWith the affixed signature. I / We the parent(s) / guardian(s) give permission for my/our son/daughter/ward to travel and remain at an approved place for a specified period living in a Lions or Lions approved home or Lions camp. I/We agree to relieve any Lions member or host family, Lions Club, Lions District or Lions International of any financial or other responsibility in the case of his/her illness, death, legal or moral irresponsibility, and to indemnify them in respect of any expenses incurred.I / We also agree that the boy / girl will not be permitted to drive a motor vehicle while away under this Youth Exchange Program. The boy / girl will return to his/her home at the completion of the exchange, unless I / We send written permission and financial means and designate where else the boy / girl is to go. In such instances the Lions supervision will cease when the boy/girl leaves the host of the Lions or the Lions camp. I / We furthermore agree that the rules of the program will be complied with by us. In the case of violation of the rules. I/We understand that my/our boy/girl will be returned to his/her home at my/our expense. I / We the parent(s) / guardian(s) give legal consent for the Lions hosting our youth to give him/her any immediate medical treatment, including surgical emergencies, as prescribed by a fully qualified doctor, when time does not permit the obtaining of consent by me/us.:III. AUTHORISED YCE CHAIRPERSON RESPONSIBLE FOR THIS FORMClub Chairperson:District YCE Chairperson: Authorised YCE chairpersonI have been briefed by the Lions about the YCE program and I have carefully read all instructions and terms in this form. With the affixed signature I fully commit to participate in the YCE program which I might be accepted to. With the affixed signature I certify that applicant is qualified to participate in the Lions International Youth Camp and Exchange Program, and that he/she and the family have been fully informed of the program s regulations and objectives. Furthermore I certify that the applicant will be fully insured to cover any and all contingencies, including repatriate, accident, medical, personal effects and personal liability during the entire duration of the applicant's travel and visit in the accepted country.If accepted to participate in the Lions International Youth Camp and Exchange Program, I will abide by its policies and procedures.I fully understand that extended personal travel or leaves during the program are not permitted, even to visit close friends or relatives, unless written permission is included with this application. I understand that my participation in the program is not for the purpose of tourism, formal education or employment, and that I will not be allowed to operate a motor vehicle during my visit in the host country. Any serious violation of the program's policies and regulations on my part can, at the discretion of the YCE-chairperson, result in the immediate termination of my visit at my expense.MD or D YCE name+VII. LIONS MULTI DISTRICT OR DISTRICT DATAe LIONS CLUBS INTERNATIONAL YOUTH EXCHANGE (YCE) Multiple District & & & & & .. 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