Legal Document Checklist

Legal Document Checklist 1. Parental permission form 2. Release statement 3. Student Conduct Agreement 4. Single parent form stating legal guardianship (only for students living with a single legal guardian) 5. Permission for picture to appear on website 6. Medical Authorization 7. Copies of passport – 4 8. Copy of insurance form or the name and policy number _______ _______ _______ _______ _______ _______ _______ _______ ALL SIGNED FORMS MUST BE NOTARIZED Mrs. Pond in the HHS main office is our notary. PARENTAL PERMISSION FORM Everyone under the age of 19 must have a notarized Parental Permission Form to travel. If both signatures are unobtainable by reason of: 1. Single parent 2. One parent is deceased 3. Parents divorced or legally separated 4. Legal guardianship or adoption Then the minor must carry an affidavit stating the same as well as signing the below document. We hereby give permission for our son/daughter, ______________________________________________ to travel to Germany with Amanda L. Beck and all other chaperones in the summer of 2009. We also give permission to partake in any excursions during the trip, either with Amanda L. Beck and other chaperones, or with their host family. __________________________________ Parent/Guardian Date __________________________________ Parent/Guardian Date RELEASE STATEMENT We/I, ___________________________________________________________________, hereinafter referred to as “Parents”, the parents and/or guardians of ________________________________________________________________, hereinafter referred to as “Student and/or Traveler”, hereby execute the following RELEASE for the trip to Germany the summer of 2009. This release is made in favor of Amanda Beck, the Tippecanoe School Corporation School Board, Tippecanoe School Corporation and all persona affiliated to these people/institutions, hereinafter referred to as “Releasees”, and all affiliates, and successors, and delegated and assigns, and all officers, directors and employees of said Releasees, including all other adult chaperones and their affiliates. Parents hereby acknowledge that Releasees have no liability or responsibility whatsoever with respect to the travel abroad program. Parents and Student/Traveler release and waive all claims, now or in the future and agree not to sue the school for any personal injury, death, property damages or loss that the Student/Traveler may sustain during or as a result of the program. In consideration of this RELEASE, the Student/Traveler is permitted to participate in this trip and all activities related thereto. In the event that the Student/Traveler should, prior to the commencement of the program, be expelled from school or otherwise disciplined by Tippecanoe School Corporation or the local, state or federal authorities, or if the Student/Traveler fails to meet any requirements for participation in the program as set forth, the Student/Traveler may be declared ineligible to participate in the trip and application withdrawn subject to the refund policy described in the travel company’s agreement. In the event that the Student/Traveler should require medical treatment while on the trip and/or any of the activities related, Parents agree that Releasees shall have the right and responsibility to secure the same without unnecessary delay. Parents hereby release Releasees from any and all liability for the quality or timeliness of any such medical care. Parents agree to reimburse Releasees for any expenses incurred during such treatment. Parents hereby acknowledge that if the Student/Traveler acts in an inappropriate manner (such as drinking, drugs, theft, extreme disrespect, etc) Releasees shall have the right to return the Student/Traveler to Lafayette, Indiana via the first available means of transportation. This with the understanding that we, the Parents, shall cover all the expenses from the moment the decision is made, the night at the hotel, meals, taxi, porters and any other expenses necessary for such return. No refund will be granted whatsoever; neither the company nor any Releasees have any obligation or any other responsibility toward the Student/Traveler from that moment on. Parents and the Student/Traveler hereby release said Releasees from any and all claims for loss or damages, including, but not limited to, personal injury or death, whether or not caused by “negligence”. The Parents and Student/Traveler volunteer hereby to assume all risks related to the trip. This release binds the Parents and Student/Traveler’s spouse, heirs, legal representative and assigns; if any portion of this release shall be held invalid under the laws of the State of Indiana or any other related to this trip, those parts not held invalid shall continue in full force and effect. And as we, the Parents and Student/Traveler and all other related or not, shall consider this document as valid in all its full contents of all the releases stated in all above paragraphs thus making all portions valid under any law from any state, country, or location, and all release in favor of said Releasees stated in the above paragraphs of this document. In Witness whereof, Parents and Student/Traveler have read and acknowledge the above release. By the signature below it is inclusive and binding of the Student/Traveler whom acknowledges Parents signatures. _____________________________________________________________________Parent/Guardian ______Date _____________________________________________________________________Parent/Guardian ______Date GERMAN-AMERICAN PARTNERSHIP PROGRAM (GAPP) STUDENT CONDUCT AGREEMENT My son/daughter _______________________ has my permission to participate in the Harrison High School – Karl Friedrich Gymnasium GAPP exchange in July 2009. This trip is school-affiliated and will be conducted under the supervision of Mrs. Amanda Beck. I understand that the trip will involve sightseeing stops in some or all of the following and possibly others: Mannheim, Berlin, Cologne, Munich, Stuttgart, Dresden, Füssen and Dachau. The trip will also include a three-week stay in Mannheim, during which time the student will live with a host family and attend school at the Karl Friedrich Gymnasium in Mannheim. I further understand that during the trip the following means of transportation may be used: airplane, train, bus, boat, subway, streetcar, bus, taxi, private cars driven by the German teacher, the host parents, and/or Mrs. Beck, and bicycle. My child and I agree to the following guidelines governing student conduct during the trip: 1. Students acknowledge that their behavior while abroad will reflect on themselves, their families, their teacher, their school, and their country, and that they will thus attempt to conduct themselves so as to leave a favorable impression on all with whom they come into contact. Mature and courteous behavior is expected at all times. Students will follow all rules and instructions given by Mrs. Beck, observe all Harrison High School rules and the rules of the Karl Friedrich Gymnasium, as well as the rules of their host families. Students will observe all arranged meeting times and curfews established by Mrs. Beck. During the sightseeing portions of the trip, students will not leave the hostel individually or in groups unless accompanied by Mrs. Beck or with her express permission. During the sightseeing portions of the trip, the group will generally remain together. From time to time we might agree to split into smaller groups for certain defined periods of time, but at no time will any student set off on his/her own, i.e., students will always remain with at least one other member of the group. During the stay in Mannheim, there may be times when the student will be on his/her own, but the student should make sure that someone (host parent, partner student, Mrs. Beck, etc.) knows where he/she is at all times. Students should also have permission from their host parents/Mrs. Beck to travel in Mannheim on their own. Students will attend school in Mannheim as specified by Mrs. Beck and be prepared to give the presentation(s) on American culture that they will prepare. If they should need to miss school due to illness, they will inform Mrs. Beck by telephone that morning before school. The primary language to be used in Mannheim is German. During the stay in Mannheim, students will live in the homes of their host families. If situations or conflicts arise with the host family that make the living arrangement untenable, they should be brought to Mrs. Beck's attention immediately so that other arrangements can be made, but under no circumstances should students take it upon themselves to alter their living arrangements or to spend the night elsewhere. Students will assume responsibility for their own belongings and will take special precautions to protect their money, ATM/cash cards, passports, and train and airplane tickets. Students will at all times show respect for private and public property, i.e., they will refrain from vandalism, willful destruction of property, and theft. Students will at no time operate a motor vehicle or buy, possess, or use tobacco products. 2. 3. 4. 5. 6. 7. 8. 9. 10. Students will not buy, possess, or consume alcoholic beverages of any kind or drugs that are illegal in Indiana, regardless of whether this will be legal for them in Germany or any other country they might enter. 11. Consequences for violations of these guidelines may include, but are not limited to, warnings, “conference calls” with the parents, and being restricted to staying within the sight of Mrs. Beck during all waking hours. Major violations (involving possession or use of illegal drugs, illegal acts, abuse of alcohol, or chronic violations of rules and curfews) may result in the student’s being sent home immediately from the nearest airport, at the parents’ expense. In addition, infractions will be reported to the school, which will treat them as if they had happened on any other field trip – which would bring into play the usual range of consequences such as suspension, exclusion from honor societies, sports, etc. 12. Breaking the rules jeopardizes everyone in the group. If necessary, the entire group may be sent home with no refunds if anyone covers up for the violators. The violators may be placed in restriction or be sent home with the “friends” who covered up. _____________________________________ Parent signature _____________________________________ Student signature _________________ Date _____________________________________ Parent signature SINGLE PARENT PERMISSION FORM I, ________________________________________________________ testify in front of the undersigned authority that I am legally a single parent and I do have all right to my child, __________________________. The undersigned can testify in my behalf as to the legality of my authenticity. __________________________________ Parent/Guardian Date PERMISSION FOR STUDENT’S PICTURE TO APPEAR ON THE GAPP EXCHANGE PROGRAM WEB SITE While on the GAPP exchange in Germany, we will be periodically taking pictures and reporting on what is happening in Germany. We will upload this to our web site for the parents to keep up with what we are doing. We will also be taking pictures during activities here in Lafayette as well as on excursions to other cities in the United States and in Germany. My son/daughter ____________________ has my permission to have his/her picture taken and displayed on the GAPP portion of the school’s web site. I hereby agree that my son’s/daughter’s picture and/or first name may be shown on the school’s web site. _________________________ Parent Signature _________________________ Student Signature __________________ Date __________________ Date MEDICAL AUTHORIZATION FOR TREATMENT OF MINOR On rare occasions, an emergency requiring hospitalizations and/or surgery develops. Since minors may not, as a rule, be administered an anesthetic or be operated on without the written consent of the parent or guardian, we request that parents or guardians sign the following statement. Every effort will be made to contact the parents or guardians before any major treatment. This is to prevent a dangerous delay in case an emergency does occur and we are unable to contact parents. In the event of injury to our son/daughter/ward ________________________________________ born _______________ we hereby authorize Amanda Beck to secure whatever treatment is deemed necessary, including the administration of an anesthetic, surgery, dental treatment. _________________________ Parent Signature __________________ Date _________________________ Parent Signature __________________ Date Insurance Health insurance: The health insurance of the parent/guardian is sufficient to use overseas, HOWEVER, the company must be contacted to make sure the policy is world accepted. Everyone must check with his or her insurance company. There will also be additional health insurance purchased for each student. This will cover healthcare required while in Germany, so that we shouldn’t need to pay for service and then be reimbursed upon return to the United States. This insurance also covers the host family’s home in case of accidents where something is broken (windows, doors, etc.) Travel insurance: There is also the option to purchase additional travel insurance. STA offers travel insurance at reasonable rates, which covers loss of luggage, trip cancellation, etc. Please call STA Travel at 280-8906 (State St. branch) or 263-9910 (Langdon St. branch) for more information. NOTE: The name and policy number of your insurance company must be given to Frau Beck before departure, as well as the form stating whether or not you choose to purchase travel insurance. PASSPORTS ATTENTION: It can take anywhere from 6-10 weeks to obtain a passport. If you do not currently have a valid passport (one that will still be valid in 2009), please apply for one immediately. If you do not have a passport at the time of departure, you will NOT be allowed to go. How to get a passport: 1. Fill out the attached forms. a. NOTE: Pages 3 and 4 of the form MUST be presented and signed in person at an authorized passport acceptance facility. i. This may be done at the post office. b. NOTE: You will need the official birth certificate. If you do not have one, you will need to request one immediately. c. NOTE: DO NOT SIGN THE APPLICATION UNTIL YOU TAKE THE OATH ADMINISTERED ONLY BY AN AUTHORIZED PASSPORT AGENT. 2. Obtain 4 passport pictures. (2 are extras in case you lose your passport.) a. These may be taken at CVS, Walgreens, Kinkos, etc. 3. Appear in person (both the child and the parent) at the post office. a. If you are under the age of 18, a parent must go with you. 4. Pay the passport fee. a. Under 16 years old: approx. $82 b. Over 16 years old: approx. $97 I NEED FOUR COPIES OF YOUR PASSPORT. YOU KEEP ONE COPY AND RETURN THE OTHER THREE TO FRAU BECK. Medical Information Form Name: __________________________________________________________________ Date of Birth: ____________________ Emergency Contact and Telephone Number: ___________________________________ Health Insurance: ________________________________________________________ Allergies/Medical Conditions: ______________________________________________ _______________________________________________________________________ Medications Currently Taking/how often: _____________________________________ ________________________________________________________________________ Is the student permitted to administer the medication(s) themselves? ________________ Is the student permitted to administer over-the-counter remedies themselves? _________ I, ___________________________________, the parent/guardian of ______________________________________ permit Amanda Beck to provide over-the-counter medications while on the Germany/GAPP Trip. I allow ________________________________________ to administer the following themselves __________________________________________ (list medications) which they may carry on their person. Signature _____________________________________ Date __________