Application & Indemnity Form – Waterton Lions Leadership Camp

Lions Club International

Youth Camp And Exchange

APPLICATION AND INDEMNITY FORM

Applicants YCE Students from(Country):

I. PREFERRED YOUTH CAMP AND EXCHANGE ALTERNATIVES

Possible Dates for Exchange (from):

Possible Dates for Exchange (to):

First Country Preference:

Second Country Preference:

Third Country Preference:

IMPORTANT !! Make sure when you fill in your choices 1, 2 and 3, dates of camp AND homestay match with dates you are available. Also check you have the correct age.

II. APPLICANT´s BASIC DATA; (if not available for the moment: mention "in request" or mention "NO")

Gender:

Male Female Others

Passport/ID/CNI Number:

Passport/ID/CNI valid until:

Passport/ID/CNI place of issue:

Have you previously participated in a Lions Youth Exchange Program? (X)

Yes No

If yes, where and when?

Hobbies & Other interests:

Knowledge of English: (X)

Good Fair None

T-Shirt Size:

Other languages spoken:

Are you a LEO (X):

Yes No

III. APPLICANT'S ADDITIONAL DATA (as applicable and available; if not available for the moment: mention "in request" or mention "NO")>

Additional Health, Medical, Dietary and Insurance Data

Capable to participate in sport activities?

Yes No

Can you swim?

Yes No

Do you Smoke?

Yes No

Disability if any: (X)

Yes No

Special Medication: (X)

Yes No

Medical/Religious/Other dietary requirements: (X)

Yes No

Allergies: animal, insect, food..

Yes No

Health Insurance Company:

Liability Insurance Company:

Any other point to be noticed:

Covid 19 Information: Full Vaccination?

Yes No

Family Doctor if you have one (Name)

IV. APPLICANT'S FAMILY DATA / Information if we need to have contact with the family

Name of parent or guardian responsible for the applicant and who is signing this form

Contact Mobile Phone:

Emergency Contact Email:

Emergency Contact Phone:

V. RESPONSIBLE LIONS CLUB DATA

Basis of financing of the exchange (X):

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. Including the responsibility to host incoming youth in exchange.

VI. LIONS MULTI DISTRICT OR DISTRICT DATA

District YCE Chairperson:

District: D or MD Nr.

VII. AUTHORIZED YCE CHAIRPERSON RESPONSIBLE AND CONTROLLER FOR THIS FORM

District: D or MD Nr.

VIII. AGREEMENT AND COMMITMENT BY APPLICANT (Please read carefully)

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.

I 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. Furthermore I certify I am sufficiently insured to cover any and all contingencies, including repatriate, accident, medical, personal effects and personal liability during the entire duration of my travel and visit in the accepted country.

IX. INDEMNITY AGREEMENT BY PARENT OR GUARDIAN

With 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. Furthermore I certify that the applicant will be sufficiently 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.

Are you from a country of Europe?

Yes No

If "Yes" you must fill in chapter X

X. Lions Youth Camp Exchange GDPR Information and Consent form only for European Countries

By signing this Form, I consent / I agree my personal data (“Data”) included in the Lions Youth Camp and Exchange (“YCE”) Application Form, ID/passport copy, health and travel insurance data, letter to the Host Family and attached photos being processed and stored by the relevant Lions Organization and persons as described further in this document.

The data will be processed/stored by Youth Camp and Exchange

Data protection officer if any (Name):

Purpose of data processing: Participation in the Lions Youth Exchange Program. Legal basis for the processing: L 119/40, Official Journal of the European Union 4.5.2016, paragraph 6.1. Recipients of the Data: Local sponsoring Lions Club of the sending Country, local YE chairperson of the sending Country, YE chairperson of the receiving Country, YE Camp organizing local Lions Club of the receiving Country, Host Family in the receiving Country.
In case of receiving Country is not a member of the European Union, the Data may be transferred to, processed and stored by the above recipients in the relevant third Country also outside the EU.
The Data will be stored until not later than 30 days after the end of the local YE activities in the receiving Country. The Participant has the right to request from the controller access to and rectification or erasure of personal data or restriction of processing concerning the data subject or to object to processing as well as the right to data portability; the right to withdraw consent at any time, without affecting the lawfulness of processing based on consent before its withdrawal; the right to lodge a complaint with a supervisory authority: name, address, phone and e-mail of the Data Protection Authority of your country.
Failure to provide the Data may have as consequence the exclusion from the Lions YE program. There is no automated decision-making, including profiling, referred to in Article 22(1) and (4) in the process. The controller does not intend to further process the personal data for a purpose other than that for which the personal data were collected.

I have read and understood the above and I consent / I agree my personal data being processed and stored as described:

XI. Lions Youth Camp Exchange DPA Information form

D/MD Data Protection Authority (DPA)

Letter to "Dear Host Family":

a copy of the applicant's passport or identity card (ID) or CNI or an equivalent identification document as required for the applied countries

scan of visa if any, a scan of your European Health Insurance Card (EHIC) for applicants out of Europe a similar insurance card and a scan of 4th page

Lions Club International

Youth Camp And Exchange

APPLICATION AND INDEMNITY FORM

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