PROGRAM PERTUKARAN PELAJAR DAN JARINGAN PENDIDIKP,N A.NTARABANGSA 2O].5 Sila Tanda program yang anda ingin sertai; fl erogram KeJepunSiri ( Protram L=] Ke Korea Siri ( London L__.1 Siri ( ) / I Australia Siri ( ) i--l Europe siri ( ) I ) ) MAKLUMAT PERIBADI Nama (Seperti di pasport ) Alamat Tetap No Kad Pengen alan: Passport No : Warganegara No. Telefon Rumah/tel birn bit Tarikh Lahir Nama Sekolah/Tingkatan LATAR BELAKANG PENDIDIKAN Nama Sekolah Alamat Sekolah / No. Telefon KEMAHIRAN BAHA.SA Tu lisa n LATAR BELAKANG AKTIVITI LUAR Senarai aktiviti Ko-kurikulum yang di sertai Pengetahuan Ja ngka waktu Penglibatan / Kemahiran lstimewa ( Kraf tangan, Bermain muzik, tarian dll ) Maklurnat Terperinci keahlian dalam kelab, persatuan atau pertubuhan leOasl1@ Ma kl umat terperinci men genai nen8libat-rn negeri, seminar atau lawatan sambil belajar (jika ada ) P e rca kapa n LATAR BELAKANG KELUARGA Pekerjaan MAKLUMAT LAIN Apakah yang anda dapat sumbangt an lit<a Apakah yang anda harap / terpilf, menftrtai program :nif belajar apubilu sel"i.irneny"rtai Maklumat kesihatan ( penyakit / Alahan ) p.g.o, ini? VII ORANG YANG PERTU DIHUBUNGI JIKA BERGKUTECETV1ASAN Hubungan \4II No. Te lefon No. Fax PENGAKUAN saya dengan ini mengaku bahawa segala maklumat yang diberikan di atas adalah benar dan betul sepanjang pengetahuan saya dan sedia disingkirkan serta merta aoabira terpirih jika terdapat sebarang kenyataan palsu atau yang tidak benar. Jika terpilih, saya setuju mematuhi segala peraturan yang telah di tetapkan oleh pihak penganjur. Ta n datanga n Peserta ffi ,F-"ry NA \a&, {q@ Helab Antarabarl$sa Hiroshima International Club Malaysia Transnational Exchange School Program MED]CAL RELEASE AUTHORIZATION HIF]OSHIMA. KUALA LUMPUF WE, as parents of the undersigned student, do hereby authorize Hiroshima lnternational Club Malaysia, the Coordinators concerning with this program and the host parents to act as agenits of the undersigned parents to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or treatment or hoSpital care which is deemed advisable by and is rendered under the general supervisions of any licensed physician or surgeon, whether such treatment or diagnosis is rendered at the clinic of said physician or surgeon or at a hospital. It is understood this authorization is not given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agents to give specific consent to any and all such diagnoses, treatment or hospital care which the aforementioned physician or surgeon in the exercise of his/her best judgment may deem advisa ble. This authorization shall be valid for the entire duration of the Hiroshima lnternational Club Malaysia program in which the student is participating. Parent'5 Signature or Legal guardian Date: Month / Day/ year Name: t/c : Studenfs Signature Name: vc: Datei Month / Day/ year qfiw -<Ef ,Gr- &ya Helab Antarabanqsa Hiroshima Inlcrnational Cilub Nia Irl,sia 'l-ransnational ijxchirnqc School 1'r'ogiant 'I'EIIM & COI.JDI'I'I 0nvS I.iIROSI IIMA. KUAt-A LUMPL]I] Below are the Hiroshima lnternational Club Malaysia' s terms of participation. Please read carefully and sign your name after you fully understand and agree to comply with these rules. 1. 3. 4 5. 6. 7. B. Hiroshima lnternational Club Malaysia Transnational Exchange students must abide by the laws of Malaysia and by the rules of the school thai they attend. Students must aiways be al.u,are of their responsibilities as an exchange student and make a determined effort in programmed. Students who are expelled from the program due to poor behavior will be sent home at their own expense. Students cannot change host families or schools at will. Students are expected to respect their host family. The most important things are to try to create a good relationship and communicate wiih host family n:mbers. The students will becorne one of the family members. students must obey host famil rules. fc, , <ample curfews an,j iiouseholti chores. Siucients may not have guests in the host family's home without their host p a rent's perm ission. Studenis are not permitted to talk about the host family's private affairs to others. St:rCe:r1: ::ust :hcw '::ieci Ior il-re :ffircr- f orrr iviirrr>iry of Ecjr,ca'.ion iviaiaysia, rllroshima lnternational Club Malaysia coordinators (staff members), and the regional represeniaiive cf Hiroshima lnternationalClub N4alaysia and obey their instructions. Stucjerrts n'rav not mal.a arv clecisirns 66 l3lrg :nw 3:'.ia^ th r,. niay :ha:;e thi nature or ,-Cur-5g of their life, i.e. getting married, changing religion, etc. Si'rdents must not padiclpate in any se>lual contact or sexual activity that is inappropriate for m ino rs. 9. Studenis are not perrnitr'ed to go on trips alone or hitchhii<e. A ti-ip with the host family or any cther responsible adult is allowed if permission is gii,en from the parents, the hcst parents and the Coordinator of Hiroshima International Club Malaysia and Ministry of Education Malaysia and an itinerary is submitted beforehanri. Students are not allowed to travel while school is in session. 10, students are not permitted to participate in sky diving, hang gliding, parachute jumping or any lth er dangerous acrivities. ll Students are not permitted io drive any motor vehicles or obtain a driver's license while participating in the exchange program. 12. Students are not allowed to purchase or shoot guns of any type. 13. Siudents may not use drugs except those prescribed by a licensed pl-iysician or "ovei- the counter" nredications such as aspirin. 14. Students are not permitted io purchase or drink alcoholic beverages. Students are also not permitted to smoke. These activities are illegalfor all persons under 1g years old. 15. Visits by members of the student's biological family from the home country of the exchange students cannot be arrowed. Visits by the friend of the exchange student from his/her home country cannot be arrowed. 16. Hiroshima International CIub Malaysia Transnational Exchange students are expected to return to their native country on the date that the Hiroshima lnternational Club Malaysia s,recifies. The coordinators of Hiroshima International Club Malaysia, your host family and the Ministry Of Education Malaysia will not be responsible for you after the end of the program. 17. Students are not allowed to have cell phones. The guidelines concerning the cell phone ' are set by Ministry of Education . I usage understand that lam responsible for obeying all Hiroshima International Club Malaysia Transnational Exchange proSram rules. I also understand that failure to abide by the above rules may result in my dismissal from the Hiroshima lnternational Club Malaysia Transnational Exchange program, termination of my student visa, and r may be sent home at once at my own expense. Signatu re of Student : D ate: NAME t/c Sign atu re NAME t/c of Parent Date: qr -4 # A Kelah Arttapabarlg$a I i Iiroshinra lnlernational Club It4ala),sia 'I lirnsn:rtional Ilxchanqc School I)rogran.t I,JAIIII I'IY II.FJI,i]ASI: IIFOSI.iIMA. KUALA LUMPUB Student's Name: I hereby release the Hiroshima lnternational Club Malaysia and all of their employees and field representatives, and host families from all liability. injury, damages or claims inat lhave incurred after the termination of the program. Further, I understand that I will not be covered by any insurance policy after the program has been terminated. The undersigrred, as a student on the Hiroshima lnternational club Malaysia program, and the parents/legal guardians ofthe student on the pi-ogram, renounce any claim against the Hiroshima lnternational Club Malaysia, the coordinator , regional representative, ieachers, counselors, scirools vrhere the students may be assigned, or an)' Jerson i:-.. rening in the orogram, thai might ar-ise due to injury, damage, sickness, accident, delay, unusual circumstances or expenses due to strikes, war, atmospheric conditions, quarantine, government restrictions or regulations, or those derived from acts of omission or airlines, shipping companies, railroads, buses, transportation in eeneral. hotels, restaurants or any other service given by ccmpanies, individuals or anyoae related with the afore me ntio n ed. vv'e ullderstarrd that the siu.ient wiii be subject ro the rules of the oi-ogram, host famiiy, school, teachers, and community where he/she will live. We also understand that Hiroshima lniernaticnal CIub Malaysia reserve the right to terminate any student who participates in the program whose conduct may be considered iJ-.trimental or incompatible with ihe interest and securitv of the program. lf this decision is ever taken, the student and his/her parents/legal guardian will have no right tc any refunds. We accept the t'ight for the Hiroshima lnternaiional Club Malaysia to directly, or indirectly, change, cancel, or substitute, in emergencies or whenever normal circumstances change, those parts of the program whose alteration may be considered necessary. We also accept the right of the Hiroshima lnternational club Malaysia to change, before departure, the cost of the program to meet unexpected changes in airfares or the price of transportation in general, monetary devaluations, etc. We understand that should there be a geographic move of the students for any reason whatscever, the cost of the transportation l.hall be borne by the student. We grant the permission of Hiroshima lnternational CIub Malaysia and permission to use in the future any photograph or any other type of material in which the student may appear, for promotion or publicity of the programs of Hiroshima lnternational Club Malaysia. We also agree we will not make contact, directly or indirectly, with schools, regional representative, host families and friends for the purpose of sending future students to any of the said schools, the coordinators of Hiroshima lnternational CIub Malaysia, families and friends. The student and natural parents/legal guardians agree to uphold the standards set by the Hiroshima lhternational Club Malaysia, the school and the family with -whom the student will rive, for the duration ofthe program. The student also agrees to miintain friendly and respectful relations with teachers, classmates, and aI famiry members, and to accept and folrow rures of conduct imposed by said family and to participate in family life as much ,, porriblu. Signature of Or Guardian NAME t/c Pa rent Date: PROGRA.M - PROGRAM YANG DI JALANKAN OLEH KELAB ANTARABANGSA HIROSHIMA PADA TAHUN 2015 Kelab dengan kelulusan dan kerjasama Kementerlan Pelajaran Malaysia (Bahagian Kesenian & Kokurikulum) akan menganjurkan program antarabangsa ke negara-negara seperci Jepun, Korea, Australia, United Kingdom dan Jerman pada cuti persekolahan Iahrn 201.5. Berikut aoa,an butjr-bJr,r p'ograrr terseoul; 1. MAKLUMAT PRO6RAM .iltr.. ,Ko'otit Program Pertukaran Pelajar dan Jaringan 1 Pendidikan Antarabangsa ke Jepun Siri 41 01Jun -9lun 23 Nov - 2 April 2015 2015 RM 4,850.00',f Tingkatan L - 6 35 Pro8ram Pertukaran 2 Pelajar dan Jaringan Pendidikan Antarabangsa l 1 Dis 2015 Sept 2015 RM 4,850.00+ Tingkatan 16 105 ke J epun Sifl 42 Program Pertukaran Pelajar dan Jaringan 3 Pendidikan Antarabangsa ke Jepun 7 - 15 Dis 2015 l Sept 2015 RNt 4,850.00* 2 Aprll 2015 RM 4,8s0,00* 1sept 2015 RM 4,850.00* Tin8katan 16 4A siri 43 Program Pertukaran 4 Pelajar dan Jaringan 01 Jun Pendidikan Antarabangsa ke Korea siri 9 - 19 lun 2415 Tingkatan 16 40 Program Pertukaran 5 Pelajar dan Jaringan Pendidikan Antarabangsa ke Korea 7 * 15 Dis 2015 Tingkatan 15 40 siri 10 Program Pertukaran 6 Pelajar dan laringan Pendidikan Antarabangsa ke 1 - 1.0 Jun 2015 l April Tingkatan 2015 1- 6 4A Australia siri 12 Program Pertukaran Pelajar dan Jaringan Pendidikan Antarabangsa ke 02.lun 23 Nov - 01 Dis 2015 l Sep 201.5 RM5,950.00* TinBkatan 1- 6 40 Australia siri 13 ProBram Pertukaran 8 Pelajar dan.Jaringan Pendidikan Antarabangsa ke Lolrdon siri 7 9 Program Pertukaran Pelajar dan Jaringan Pendidikan Antarabangsa ke London siri 8 02lun - 11lun 2015 16-25 Nov 2015 1April 2015 RM 6,850.00', l RM 6,850.00* Sep 2015 Tingkatan 1. 6 Tingkatan 1- 40 40 ProBram Pertukaran P 10 nd id ika.r ke Europe 11 la elaja r dan Pe nBan Antarabangsa !in I 02 iun ( 11 Jun 015 2 Amsterdam - Belgrum Paris l Program Pertu karan Pelajar dan Jaringan Pendidikan Antarabangsa - 16-25 Nov 2015 I Apfil 20.15 15ep 2015 liM 7,450 00, Rrvl 7,450.00* ke Europe siri 2 ( Hungary . Venice " Prague Tlngkatan l- tr Tingkatan 16 40 40 ) *5ila rujuk lampiran 2 2, SYARAI-SYARAT PENYERTAAN Silo ru juk Lompiran 7. 3, YU R,^ N PENYERTAAN Yuran penyertaan perlu ditanggung oleh ibubapa/penjaga dan perlu dibayar sepenuhnya mengikut jadual pembayaran yang telah djtetapkan. Segala pembayaran perlu dibuat menggunakan CHEQUE ATAU BANK DRAF SAHtuA kepada KELA.B ANTARABANGSA HIROSHIMA KUALA LUfvIPUR sebagai penerima. Jadual Pe m bava ra n RM 2000.0c 1 Bersama Borang Permohona 2 Pada atau sebelum 2 minggu selepas surat tawaran di keluarl<a n . .. n Baki Yuran Wang pendahuluan sebanyak RM 2000.00 tidak akan dikembalikan jika peserta menarik diri dari program selepas menerima tawaran. Walaubagaimana pun bagi pelajar yang tidak terpilih, deposit sebanyak R l\4 2000 00 akan dikembalikan' Kos pentadbiran sebanyak RM 3OO.O0 akan ditolak jua sebab setelah borang permohonan diterima. jika pelajar menarik diri atas apa Jika Peserta telah membayar keseluruhan yuran pendaftaran dan 'menarik diri kemudiannya, amaun pembayaran balik hanya akan dibuat setelah ditolak deposit yang telah dibayar oleh pihak urusetia program kepada pihak syarikat penerbangan/ hotel, pengangkutan dan kos pentadbiran seperti di atas. . Kos ini tidak termasuk surcaj yang dikenakan oleh pihak MAS atau syarikat penerbangan Iain (jika ada) dlsebabkan peningkatan harga bahan ap atau sebagainya. . 4. Senarai lengkap kos penyertaan seperti di Lampiron 2 INSURAN Pihak kami akan menyediakan insuran kema la ngan/nya wa yang akan melindungi peserta bermula pada tarikh berlepas di KLIA sehingga pulang ditempat yang sama lnsuran ini juga meliputi segala kos rawatan sebagai pesakit luar jika peserta mengalami sebarang masalah semasa program ini berlaian. 5. PENGISIAN DOKUMEN PEMERIKSAAN PERUBATAN Pesefta hendaklah mendapatkan perkhidmatan doktor yang bertauliah semasa mengisi dokumen ini, Pihak penganjur dak bertanggung jawab jika maklumat yang diberikan adalah palsu cjan penyertaan peserta akan di batalkan seTta merta jika didapati memalsukan tahap kesihatan anda. Dokumen ini perlu diisi selepas mendapat surat tawaran dan diserahkan semasa pendaftaran kursus. 6, PERMOHONAN VISA Pihak Kelab akan menguruskan permohonan visa semua peserta dan guru pengiring bagi negara -negara yang memerlu kan visa . Pemohon dikehendaki menyediakan passpod Antarabangsa yang masih sah ( tarikh tamat tempoh wajib melebihi program )serta lain-lain dokumen yang akan dimaklumkan kemudian' 6 bulan dari tarikh KURSUS PERSEDIAAN Peserta dikehendaki menghadiri kursus persediaan sebelum proSram sebenar berlangsung, Kursus ini bertu.juan untuk memberikan maklumat setiap program den8an lebih lengkap, latihan kebudayaan dan mempererat hubungan di antara peserta. Kursus ini akan diadakan pada tarikh dan masa yang akan ditetapkan kemudian dan kehadiran pesefta adalah diwajibkan. Kegagalan menghadiri kursus ini tanpa alasan yang kukuh akan menyeba bka n penyertaan a nda dibata lka n 7. PRO5EDUR PERMOHONAN Pelajar yang berminat boleh mendapatkan borang permohonan daripada kaunselor sekolah maslng-masing atau memuat turun melalui sesawang http://www. hiroshimainte rnation a l.com. Permohonan mesti mengisi boring permohonan tersebut dan hantar kepada urusetia program di alamat seperti di bawah, Pemohon yang menghantar awal borang permohonan akan di berikan keutamaan, Kelab Antarabangsa Hiroshima Kuala Lumpur No. 43-14, Jalan L/ 4, Bandar Sri putra 43000 Bangi, Kajang Selangor Darul Ehsa n 8. ATURCARA PROGRAM Sila rujuk 9. lampiran 3. PERTANYAAN DAN MA.KLUMA.T LP.NJUT Sebarang pertanyaan atau maklumat lanjut mengenai program dipersilakan menghubungi urusetia program sepefii di bawah : Pejabat 03-89260881/03-89200997 En Fadzil Rabu 012-224G43I En Zaimi 0!9-666ZLO| Nabil En Fahmi - \A/ebsiie Email - En ini tuan/puan : 010-53553 31 012-3925951 http://www.hiroshima internation a hiroshima kokusaiclub@ vahoo,co m l.com
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