Form 4-2018 This form must be filled out by the chaperone, notarized, and the original sent to the Administrative Office before the visit takes place, keep a copy at school.
INTERNATIONAL SCHOOL-TO-SCHOOL EXPERIENCE (ISSE)
586 CLEVELAND AVE.
LOUISVILLE, CO 80027
Phone (303) 666-5010
Name ___________________________________________ Birth Date ________________
School Telephone ____________________________ Partner School Telephone________________________________
Dates of visit ____________________ to _________________________
RELEASE FROM LIABILITY — ADULT CHAPERONE
I, ______________________________________, hereby release International School-To-School Experience, the host school, and their trustees, officers, agents, employees, and volunteers from all liability for personal injury, sickness or damage to the personal property, except as the same may be caused by the willful or intentional act of any trustee, officer, agent, employee, or volunteer of International School-To-School Experience. Further, the undersigned hereby agree to indemnify and hold harmless International School-To-School Experience, its trustees, officers, agents, employees, and volunteers from the money damages claimed or adjudged against them jointly or severally by reason of personal injuries to, sickness of, or damage to the personal property, except as such damages are caused by willful or intentional act. The release and indemnity herein shall apply to the full period of the International School-To-School Experience.
In Witness Whereof, I have hereunto set my hand this (day) __________ (month __________ (year) __________.
PLACE NOTARY SEAL IN THIS SPACE