Student Sname: Host Club

RequestforTravelPermission – District-2240

(6– OtherTravellingoutoftheterritoryoftheDistrict 2240)

Student’sName: Host Club:

Jméno studenta Hostitelský klub

Name and aphonenumberof host family:

Jméno a telefonní číslo hostitelské rodiny

Host familyapprovedof a travelon: (dd/mm/yyyy)use thisdateformateverywhere

Hostitelská rodina schválila cestu dne

Host Clubdicusssedparticulartravellingatthe club meeting and approved-disapproved

ofthetravel on:

Hostitelský klub projednal žádost na schůzce a povolil-nepovolil cestu dne

Parents/Legalguardiansmustapproveofthistravel and sign a formsayingfollowing:

WetheparentsorlegalguardiansoftheRotaryYouth Exchange Student shownabovegivepermissionforhim/her to travel to thedestinationshownabove, at (and onlyat) thetimeshownabove, withtheothertravelarrangements, such as companions and host shownabove. Weagreethateitherthe student or wewillpayallexpensesforthattravel. In considerationforRotary’sgrantingpermission to travel to the student namedabove, wetheparentsorlegalguardians and the student, to the full extentpermitted by law, herebyrelease and agree to hold harmless and indemnifyall host parents, membersoftheirfamilies, allmembers, officers, directors, committeemember and employeesofall host and sponsorRotaryClubs, Districts and organizations, and Rotary International, of and fromallliabilityoranypropertyloss, propertydamage, personalinjuryordeath, including such liabilitywhichmayariseoutofthenegligenceofany such personsorentitieswhichmaybesufferedorclaimed by the student, parentsorguardiansduringthe period of his/her travel, includingtravel to and fromthedestinationdescribedabove, orelsewhere, expresslywaivingany and allclaimsforliabilitywhichweoranyofusassert.

Wehavereadalloftheabove and agree to these terms and restrictions:

______

Name and SignatureofFather/Mother - LegalGuardianDate

Itinerary- detailsoftravel:

Pleasespecifythepurposeoftravelling, exactdates, destinations, and timesoftravelling, meansof transport youwillbeusing (train, bus…) and a program ofyourtrip

6. OtherTravellingoutoftheterritoryoftheDistrict 2240

AnyothertravellingoutoftheterritoryoftheDistrict 2240 (travellingabroad, outofthe Czech Republic and Slovakia) mustbeapproved in advance by allfollowingparties:

• the host parents, whoinformthe Host club abouttheirdecision
• the Host Rotary Club, whichconsultsthedecision on student'sapplicationatoneoftheregularmeetings and the dis/approvalisincluded in the report
• natural parents/legalguardiansin WRITING (itissufficient to send a scanofthesignedprescribedform)
• theDistrict 2240 Youth Exchange Committee. Theapprovalwithpreviousapprovalof a host family and club mustberequestedat on a prescribedform 10 daysbeforeprojected start ofthejourneyatthelatest.