Professional Documents
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State
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Home Phone: ______________________________ Work Phone _____________________ Cell Phone: ________________________________ Email _______________________________ Parent/Guardian 2: ________________________________________________________ Address (if different) ____________________________________________________________
City
State
ZIP
Name: ___________________________________________ Relationship: __________________ Home Phone ________________________________ Cell Phone ___________________________ Name: ___________________________________________ Relationship: __________________ Home Phone ________________________________Cell Phone____________________________
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Policy Number ________________________________________ Expiration Date: ____________________________ Contract/ID number: _______________________________________ Group Number: ________________________ Primary policy holder: __________________________ Relationship to student: ________________________ Insurance Company Phone Number: __________________________________________________________
Supplemental Travel Medical Insurance (if applicable) Insurance Company ___________________________________________________________________
Policy Number __________________________________________ Expiration Date: __________________________ Insurance Company Phone Number: __________________________________________________________
Health Information:
Physical Problems or Limitations: _________________________________________________________________ Current Medication: ________________________________________________________________________ Allergies (Food, Drugs, other) __________________________________________________________________
Medical Authorization:
In the event that I/We cannot be reached to give my/our consent, I/We the undersigned parent(s)/guardian(s) of the above named student hereby authorize the identified chaperones of this exchange trip, Uwe Neuhaus, Lynn Farmer, and Brett Belcher to secure any and all medical and/or dental treatment including but not limited to, calling paramedics, consenting to x-rays, CT scans, MRI scans, other diagnostic testing, blood work, physical examinations, anesthesia, surgery, dental procedures or other medical and/or dental treatment or hospital care which, in the best judgment of a licensed physician or dentist, is deemed reasonable and necessary for the health and well being of the above named student. The undersigned parent/guardian agrees to assume the financial responsibility and to indemnify the identified chaperones for any and all expenses incurred as a result of said medical and/or dental treatment.
Parent Name Printed Signature of Parent Date
Signature of Parent
Date
Subscribed and sworn to before me in presence, this day______________ of 20 Notary Public in and for the _______________
County/State
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Signature of Parent
Date
Subscribed and sworn to before me in presence, this day ______________ of 20 Notary Public in and for the ________________________ County/State My commission expires _________________
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The Student shall respect and follow the directions of Uwe Neuhaus, all other chaperones, and any other adult associated with the activities on this trip. The student shall not be involved in any way with smoking, alcohol, drugs, vandalism, theft, or any other type of behavior that is judged by Uwe Neuhaus and the chaperones to be detrimental to the health, well-being, safety, or reputation of the student or anyone else involved with this trip. The student is expected to obey all rules and safety precautions established by Uwe Neuhaus and the chaperones during the travel and group activities Students will participate in all daily activities as determined by Uwe Neuhaus and the chaperones The student shall comply with any and all rules and regulations of the various governmental and commercial agencies associated with this trip. The student is not allowed to drive a car or any motorized means of transportation in Germany. Any driving will be considered as the illegal operating of a motor vehicle and may be reported to the local authorities. Mature, courteous, thoughtful behavior and conduct of highest quality is expected at all times. Good common sense, respect and consideration for others and their property is expected and must be practiced. Use or possession of drugs or illegal narcotics will result in the participant's immediate return to the United States at the expense of his/her parents. In the case of arrest (for the above), the student becomes the total responsibility of the student's parents Herr Neuhaus or the designated head chaperone. In such cases, the parent/guardian will be contacted and the student sent home at the parent's expense.
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STUDENT: I have read, and I understand the behavior rules and regulations stated above. I agree to comply with all of these rules and to accept the consequences as a result of my actions.
Student Signature
Date
PARENT: I have read and understand the rules and regulations stated above. I give consent for my child to attend this trip based on the conditions stated above.
Parent Signature
Date
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