INTERNATIONAL SCHOOL-TO-SCHOOL EXPERIENCE (ISSE)

ACCOMPANYING ADULT AS LEGAL AGENT

 

We, the parents of _______________________________  _______________________________  ______________

    Family Name                                       Personal Name                                        Initial

 

Mother (print) __________________________________  ________________________________  ______________

          Family Name                                                 Personal Name                                         Initial

 

Father (print) __________________________________  ________________________________  ______________

         Family Name                                                  Personal Name                                        Initial

 

hereby authorize _______________________________  ________________________________  ______________

  Family Name                                            Personal Name                                         Initial

 

hereby authorize _______________________________  ________________________________  ______________

  Family Name                                           Personal Name                                           Initial

 

who is(are) the Accompanying Adult(s) of the visiting team to ______________________________ School, at

 

Street____________________________________________________________________________________

City ___________________________ State/Province _________________ Country _____________________

 

to authorize and arrange for medical care, hospitalization and/or surgery, and to determine and undertake such financial obligations as may be necessary therefor, in the event that in his/her judgment such services become necessary for the above named child during his/her attendance at, travel to, and return from the aforementioned Host School and community with the proviso that such Accompanying Adult(s), named above, inform the parents, named above, as early as possible, making every effort to contact parents before this authorization is exercised.

 

Father’s Signature _________________________________________________________________________________

Home Address (print) _______________________________________________________________________________

Telephone________________________________________________________________________________________

E-Mail ___________________________________________________________________________________________

Business Address (print) _____________________________________________________________________________

Business Telephone_________________________________________________________________________________

Mother’s Signature _________________________________________________________________________________

Home Address (print) _______________________________________________________________________________

Telephone________________________________________________________________________________________

E-Mail ___________________________________________________________________________________________

Business Address (print)_____________________________________________________________________________

Business Telephone_________________________________________________________________________________

 

Date ___________ (day) ________________ (month) ___________________ (year)

 

 

Place Notary Seal in this Space