Borang

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