Form 3-2018 This form must be filled out by the parent or guardian, 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 ________________

School _____________________________________________        Grade _______  

School I will visit ______________________________________ Dates of visit _____________ to _______________

 

RELEASE FROM LIABILITY — STUDENT          We, the custodial parent(s)/guardians of:

(Child) __________________________                 __________________________ 

Family (last) Name                                   Personal (first) Name                                               

(Father) __________________________        __________________________ 

 Family (last) Name                                  Personal (first) Name                                 

(Mother) _________________________          _________________________ 

  Family (last) Name                                 Personal (first) Name                                                                      

Do 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 of our son/daughter, 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 parents do 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 of our son/daughter, 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) __________.

 

Signed:

 

Father ____________________________________________________

 

Home Address ______________________________________________                   Notary seal is to be placed

 

Business Address ____________________________________________                           in this area.

 

Telephone __________________________________________________

 

Email______________________________________________________

 

Mother ____________________________________________________

 

Home Address _______________________________________________

 

Business Address _____________________________________________

 

Telephone ___________________________________________________

 

Email_______________________________________________________