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)

ADMINISTRATIVE OFFICE

586 CLEVELAND AVE.

LOUISVILLE, CO 80027

Phone (303) 666-5010  

 

 

Name ___________________________________________        Birth Date ________________

Address __________________________________________________________________________________________

Telephone ________________________________________________________________________________________

Email____________________________________________________________________________________________

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) __________.

 

Signature _________________________________________________________________

 

 

 

                                            

        PLACE NOTARY SEAL IN THIS SPACE