CHAPERONE APPLICATION FORM

2016 Shanghai International Sister Cities Youth Camp

11 – 24 July 2016

TERMS AND CONDITIONS

• This program is open for participation by Queensland State secondary school teachers only. • Only one teacher may be nominated by each school. • The selection panel may select participants based on Departmental strategic priorities which may include distributing opportunities for

overseas travel evenly throughout the Department’s service delivery regions. • The decision of the selection panel will be final and no correspondence will be entered into after the results are announced. ELIGIBILITY To be eligible to apply to act as a chaperone for the 2016 Shanghai International Sister Cities Youth Camp Program, the applicant must: • be a full-time registered teacher in a Queensland state high school (or college, or academy) • be an Australian citizen, permanent resident of Australia or a New Zealand citizen residing in Australia • be healthy and fit for international travel • be prepared to abide by the Queensland Code of Ethics for Teachers • be prepared to abide by the laws of China whilst in China • be prepared to advise the Department of any changes that may affect their participation (e.g. health, family or school issues) • be willing to participate in all activities arranged by the organisers • have (or be willing to obtain) a current and valid passport (with at least 6 months validity from July 2016) • be available to travel from 11 - 24 July 2016 • accept the conditions outlined in the Privacy Statement • participate in a pre-departure briefing • write a report on their experiences after returning to Australia.

INSTRUCTIONS FOR COMPLETION TEACHER 1. Complete Section One

electronically 2. Save PDF document 3. Email to Principal

PRINCIPAL 4. Complete Section Two (A)

electronically 5. Save PDF document 6. Email back to teacher

TEACHER 7. Print document 8. Have Principal sign Section Two (B) 9. Complete Section 3 by hand 10. Scan and email application + any required

attachments to internationalservices@dete.qld.gov.au

Privacy Statement: The Department of Education and Training (DET), through DET International, is collecting your personal information for the purposes of assessing/contacting applicants and for organising and planning the 2016 Shanghai International Sister Cities Youth Camp. The information will only be accessed by DET staff administering the 2016 Shanghai International Sister Cities Youth Camp and in some cases, authorised community and/or Consulate representatives assisting DET in the selection of participants. Successful applicants’ information will be disclosed to the Shanghai Municipal Education Commission Camp organisers and travel providers for the planning and administration of: airlines, accommodation, transfers, tour operations, travel insurance, assessing/contacting applicants, selecting appropriate chaperones and or host families (if applicable) and making arrangements to cater for special requirements while in China. This will involve the disclosure of your personal information to entities outside Australia. Your information will not be used by, or disclosed to any other person or entity unless we have your consent, or DET is required or authorised by law to do so.

SECTION ONE I am: • an Australian Citizen Yes (attach scanned passport photo page to return email) • an Australian Permanent Resident Yes (attach scanned passport photo page and visa/approval to return email) • a New Zealand Citizen residing in Australia Yes (attach scanned passport photo page to return email) • willing to abide by the Queensland Code of School Behaviour Yes • willing to be responsible for the safety of students while overseas Yes

SCHOOL DETAILS School Name

Address Street

Town / Suburb / City Post Code

Principal Phone

APPLICANT DETAILS

Name Surname

Given Name/s

Gender Male Female Mobile

Position

Teaching Specialisation

Email Address School

Private

Chinese (Mandarin) Language Speaker? Yes No

NB. It is mandatory for the chaperone to speak Mandarin

Current Teaching Program/s

Subject Year Levels

PASSPORT DETAILS (please attach scanned copy of passport photo page) Name as appears on Passport

Passport Details Number Expiry Date

Country of Issue

Nationality

I am in the process of applying for my passport. NB: Successful applicants will require a passport no later than one month after closing date.

MOTIVATION FOR NOMINATING

Why do you wish to participate?

How do you envisage this trip will benefit you and your school?

PREVIOUS TRAVEL EXPERIENCE Please outline previous international travel indicating year, place and purpose (business, leisure, chaperoning group) Please outline what you think are key responsibilities for chaperones when accompanying students overseas. You may outline how you have undertaken the task previously.

SECTION TWO ENDORSEMENT BY PRINCIPAL

A

Statement of support for chaperone’s application

I endorse the above teacher as competent to chaperone students on an overseas school trip I am aware that participation in this event will result in the absence of the teacher for 10-12 school days with TRS payments to be met by International Services

B Principal Signature

Date

Principal Name (Please Print)

* Applicants may wish to attach a professional reference in addition to the above from an individual

outside of the school, particularly if relatively new to the school.

SECTION THREE ACKNOWLEDGEMENT/CONSENT By signing this Application Form, the applicant: (1) certifies that the Terms and Conditions as set out above are understood and have been met; and (2) consents to the recording, use or disclosure of their personal information as outlined in the Privacy Statement and particularly accept that their personal information may be transferred to entities outside of Australia.

Applicant Signature

Date

Applicant Name (Please Print)

CHECKLIST CONTACTS

Teacher Nomination: • Teacher details • Passport details • Reason for nomination • Principal’s statement of support

Attachments: • copy of passport photo page • professional reference (optional)

Mark Pappas Project Officer DET International Ph. 35135705 E. internationalservices@dete.qld.gov.au

Nominations close | 5:00 pm Friday 15 April 2016