Yaz Okulu

PARENTAL TRAVEL AUTHORIZATION FORM

 

Legal Parent / Guardian Information

 

Full Legal Name  
Relationship to Student  
Street Address

 

 
City/Town  
County/Region – Zip / Postal code  
State/Country  
Home Phone Number  
Work Phone and  Fax Number  
E-mail  

 

Student`s Information

 

Last, First Name  
Birth Date (month, day, year)  
Name of School Currently Attending  
Grade Level  
Passport Number  
Passport Date of Issue (month, day, year)  
Passport Place of Issue  
Does the child have special medical needs in the event of emergency medical treatment?  

 

 

Parent’s Consent

 

I, _____________________________________________________ certify that all the information I provided about my child above is correct to the best of my knowledge. I will hold no one liable for the possible consequences in any form for the insufficient or misleading information that I failed to provide with this consent.

 

Signature of Parent: ____________________________________ Date (month, Day, Year) : ________________

 

 

 

 

 

 

 

Adult or Organization Information

Please enter the following information for the Adult or Organization supervising the travel

Full legal name of the adult or organization  
If organization, full name of the individual representing the organization  
Title of this individual in this organization  
Adult’s or organization’s relationship to student(s)  
Address  
City/Town  
County/Region  
State/ Country / Zip-Postal code  
Date Leaving the Home Country  
Date Arriving the Destination  
Date Returning to the Home Country  
Trip(s) to Washington DC, Virginia, New York and Maryland
Purpose of the Trip Study English in Summer School Programs offered by Diplomatic Language School and also partially recreational purpose during the month of June and July

 

 

                                                

Parent’s Consent

In the event that I cannot be immediately contacted, the accompanying adult/organization have (initial here : ________), do NOT have (initial here: _________) the authority to make emergency medical decisions for my child. I read and understood all the information provided by the adult or organization about their identity and the nature of the trip, and hereby authorize (name of adult or organization) __________________________________________ ____________________________ to accompany my child during his/her international travel.

 

Signature of Parent: ____________________________________ Date (Month, Day, Year) : ________________

 

The purpose of this form is to inform the parents and get the parents’ consent about their child’s intention to join our short term summer school program. Any parent who has student at 18 years old or younger MUST sign this form, regardless whether or not student is traveling alone or with an adult.