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Student Personal Details

Name*

FirstLast

Date*

Today's Date

Student's Location*

Your request will be directed to your local support team!

Date of Birth -mm/dd/yyyy*

Your Gender*

Male
Female

High School*

What is your current grade in school?*

American Home Address*

Street AddressAddress Line 2CityStateZip Code

Student's Email*

Student's Cell Phone*

Consultant's or Guardian's name*

FirstLast

Consultant's or Guardian's Phone*

Family Information

Parent's Name*

FirstLast

Parent's Email*

Parent's Phone*

Medical History

Medical Insurance Company*

Insurance Policy number*

Do you take any medications, vitamins or herbal remedies?*

Yes
No

If "Yes" describe what you take and how often:

Do you have any allergies or chronic illnesses?*

Yes
No

Do you have any dietary restrictions?

If "Yes" list allergies or chronic illnesses:

Trip Details Section

Where are you traveling to?*

Arrival Date

Departure Date

Number of nights*

List how many nights a home stay will be needed

Mode of Transportation*

IBG will arrange round trip driver to school
Train-IBG will arrange round trip ride from station
Bus-IBG will arrange round trip ride from station
Boat-IBG will arrange round trip ride from dock
Plane-IBG will arrange round trip driver from airport
Transportation not needed

List how you need transportation arranged

Arrival and departure information

Please list flight# and arrival / departure times or transportation details.

Is student under 16?*

Student is under 16 years old
Student is over 16 years old

If student is under 16 years old-Guardian for Trip (Responsible Adult Over 21 Years Old)

Students under 16 traveling on plane, boat, bus or train will require guardian to accompany them.

Name of person to accompany minor*

FirstLast

Relationship to student*

Phone*

Application completed by:*

CONDITIONS AND GENERAL INFORMATION 1. I, have applied to participate in a IBG short Term Exchange Program tour program sponsored by Ivy Bridge Group. (IBG). I agree to all of the following terms, conditions, and understandings, which shall be binding upon me and upon IBG. I agree to abide by the rules and regulations set by IBG for the health, safety, welfare and management of tour members. I agree to indemnify and hold harmless IBG from any claims arising out of my participation in the tour program. 2. I acknowledge that IBG cannot be responsible to me for events beyond its control, such as (without limitation) strikes, war, delays, weather, acts of God, terrorism, or governmental restrictions; or for the actions or omissions of any persons or entities outside its control, such as (without limitation) airlines, surface transportation companies, hotels, restaurants, and other suppliers of tour services, arrangements, or accommodations. I release IBG (its employees, agents, school, and school board) from any claims arising from such events, actions, or omissions. Because IBG has no control over such events and circumstances, it cannot be responsible for any claims which may arise as a result. If I wish to obtain travel insurance, baggage protection insurance, or other insurance coverage, it is my responsibility to do so. 3. I agree to abide by the final itinerary established by IBG for my tour program. I will not depart from IBG's established itinerary at any time, either on my own or with any other tour participants, unless I submit a written document signed to IBG and such document is approved by IBG prior to departure. If I submit a written document and it is approved by IBG, I agree to honor its terms and conditions and to follow the travel plans which it specifies. The approved document shall also become a part of this agreement, whether or not it is physically attached. If I depart from IBG's established itinerary at any time during my tour (whether or not I have first submitted a written document authorizing the departure), I agree to be fully responsible for my own safety and well-being, as well as for my own conduct. I will make no claims against IBG (or its employees or agents) as a result of any events which may occur prior to the actual departure of my tour or during any time that I depart from IBG's established itinerary for my tour. IBG cannot be responsible for my well-being during the time I am traveling from my home to the point of departure for my tour, or at any time during my tour when I am absent from IBG-supervised activities. 4. I agree to conduct myself in a responsible manner at all times during my tour, follow the established itinerary, and to refrain from the use of alcohol or illegal drugs. In addition, I will comply with all group rules and standards which are announced verbally or in writing by IBG. IBG shall have complete discretion to terminate my participation in the school tour program and to send me home at my own expense (or at the expense of my parents or legal guardian) if I engage in any conduct which violates this Agreement, violates the group rules and standards announced by IBG, endanger the success of the tour or the welfare of other tour members and /or tour leaders, or is detrimental to the reputation of IBG. If I am sent home for any of these reasons, I will not be entitled to any refund. The manner and means of transporting the member home shall be determined exclusively by IBG and all expenses incidental to the termination of the tour membership (including the entire costs of the transportation of the tour member back home) shall be borne completely by the tour member and/or the tour member's parent or guardian. 5. I agree to accept responsibility for my own conduct and judgment at all times during my tour program, regardless of whether I am participating in a IBG-supervised activity. IBG is not responsible for loss of travel documents, valuables, or for loss of or damage to luggage or belongings. I specifically accept responsibility for any financial obligations I may incur and for any damages or injuries I may cause 6. I agree to complete the Medical Information Form as provided by IBG and have indicated on this form any medical conditions which might affect my participation in the school tour program. Tour members must be covered by medical and baggage insurance by their parents or guardians as IBG cannot assume any medical costs or baggage losses incurred while on tour. Trip cancellation insurance is available to protect against sudden illness of you or immediate family resulting in a doctor's orders against taking the trip. Further information is available upon request. I will notify IBG of any prescription drug use on the Medical Information Form which will be signed by my parent or legal guardian. I understand my failure to complete the form prior to the college tour departure will preclude me from participating in the program. I acknowledge that the information contained in the Medical Information Form and Application Form is true and accurate to the best of my knowledge and that I will indemnify and hold harmless IBG from any claims should any of the information contained in the Medical Information Form and Application Form are false. If I become ill or incapacitated at any time, I authorize IBG to take whatever action it deems necessary to preserve my health and safety, including (without limitation) obtaining medical treatment for me and/or transporting me home, all at my expense (or at the expense of my parents or legal guardian). I agree to reimburse IBG for any expenses it incurs for the purpose of preserving my health or safety. 7. I agree that IBG shall have the right to cancel any tour program for insufficient participation or for other reasons which it considers appropriate. In the event a tour is cancelled, IBG's sole obligation will be to provide me with agreed refund. Should the tour be cancelled after it has begun, IBG's sole obligation shall be to provide me with a refund of the cancelled portion of the tour program. I agree that I will have no right to a refund for any accommodations, meals, or services which I do not use once my tour has begun. 8. IBG's Host Family Stipend for the Short Term tour includes room and 3 meals (self-made breakfast and lunch), NOT included: flight ticket, insurance, and transportation. If I wish to cancel my reservation for the scheduled IBG tour, I must do so in writing prior to departure. My right to a refund will depend upon the date that my written notice of cancellation is received by IBG. If my written notice is received at least thirty-one (31) days prior to departure, then IBG will refund all of my money, minus the application fee and Host family Placement fee of $250.00 plus any direct expenses incurred. If my written notice is received between fourteen (14) and thirty-one (31) days prior to the departure, IBG will refund fifty percent (50%) of the total fees charged for my college tour plus any direct expenses incurred, minus $250.00. Should I cancel less than 14 days prior to the tour departure date I will NOT be entitled to any refund. Refunds will not be granted less than 14 days before the departure date due to contractual arrangements with transportation companies 9. This agreement shall be effective upon my acceptance by IBG as a participant in one of its campus tour programs. This agreement may not be modified except in writing. No oral modifications of this Agreement shall be valid. 10. I certify that I am the parent or legal guardian of the applicant named above. I have read the above Agreement and will be bound by its terms and conditions, both on my own behalf and on behalf of the applicant. 11. The Program Deposit of $350 is for such things as breakage, damage, unpaid phone bills, and repaired, etc……and is refundable. I have read, signed, and consent to the IBG Short Term Host Stay Exchange Program Conditions and General Information Sheet.*

I accept the terms

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Short Term Student -Home for the Holidays Program

Student Personal Details

Family Information

Medical History

Trip Details Section

If student is under 16 years old-Guardian for Trip (Responsible Adult Over 21 Years Old)

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