Departments » Parks and Community Development » Sister City Exchange Program - Ushiku, Japan
Tell us about your family
Please include any partners, children, pets, etc.
Please specify Name and Relationship
Alternate Emergency Contact (in case we can't reach your primary contact)
Please provide Name and Relationship
Please provide Health Care Number
Do you have any disabilities or require extra support?
(e.g. ADHD, autism, seizures, speech, hearing, etc.) If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660
Do you suffer from anxiety?
If you’d feel more comfortable discussing these issues with a staff person, please call 668-8660
Do you suffer from any allergies?
If yes please provide details.
*If you have an allergy requiring an Epi-Pen, please complete and submit the Anaphylaxis Emergency Plan along with this form.
Are you taking medications on a regular basis?
List the foods you enjoy eating:
List the foods you DO NOT enjoy eating:
Do you have any specific dietary requirements?
Does meat cause you any physical trouble?
Do you have any food allergies?
If yes please provide details e.g. nuts, dairy, seafood.
Do you require medications for your food allergy if appropriate?
What are things for your host to know about your food allergy if appropriate?
List the countries and/or provinces you have visited in the past five years, giving the duration, group size and year of the visit.
Have you participated in previous exchanges?
If yes, indicate the destination and length of stay.
Do you have a fear of flying?
Rate your knowledge of Languages other than English using GOOD, FAIR or POOR (indicate the Language, Years studied, Spoken and Written abilities)
Are you: (pick one only)
SPORTS (Provide details including approximate hours per week)
MUSIC (singing, playing) / ART (dance, drama, drawing, painting)
(Provide details including approximate hours per week)
CLUBS / GROUPS (Provide details including approximate hours per week)
HOBBIES / LEISURE ACTIVITIES (Provide details including approximate hours per week)
What is their occupation?
Please answer the following questions:
*Please attach your answers below.
1. What experience do you have interacting with youth in a group? (This can be family, work, sport or recreation related, or all of these.)
2. Have you travelled with a group of youth before? Please provide details such as locations, dates, type of group, etc.
3. Why do you want to be a chaperone and what personal attributes and skills do you bring to this position?
4. How do you manage challenging behavior from young people? If possible, please give examples of situations you have handled in the past.
5. Why do you want to visit Japan and what do you hope to gain from this experience?
6. You will be acting as an ambassador for the City of Whitehorse and the Yukon. What ideas do you have for promoting the City and Northern culture to the staff and students of Ushiku, Japan?
7. Do you have current First Aid Certification?
8. How would you continue to support the Sister City Program once you have returned to Whitehorse?
**NOTE: If selected, you will also be asked to provide a RCMP Criminal Record Check
I/WE CONSENT to my child’s participation in this exchange program and understand that he/she/we must abide by the Code of Conduct outlined for the duration of the exchange program.
MEDICAL AND DENTAL AUTHORIZATION: I authorize all medical and dental attention for my child judged necessary by medical authorities in the host country or the chaperones in the event of an accident or serious illness. I understand that every attempt will be made to reach me by telephone in case of emergency.
GROUP TRAVEL: I understand that my child must travel to and return from the exchange country with the exchange program group with exception.
TRAVELLING IN THE HOST COUNTRY: I understand that travel during the exchange program is restricted to excursions with the host family and City of Ushiku Officials, without exception.
I/WE PERMIT the City of Whitehorse to videotape and/or photograph my child while participating in program activities with the understanding that these materials may be used for promotional purposes.
EXPULSION FROM THE PROGRAM: The exchange program authorities reserve the right to immediately withdraw a student from the program and arrange for an early return home, with no liability or cost to the exchange program authorities or to the host family, for any of the following reasons: