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Chamblee Charter High School / Nuremberg-Durer Gymnasium Exchange Program Student Information Form, Student Behaivor Contract, Risk

& Liability Waiver, Medical Authorization


STUDENT INFORMATION FORM Student Name as it appears on Passport:
_____________________________________________________________________________ / _______________ Last First Middle Preferred Name

Date of Birth ___________________________ Passport Number _______________________ Student Address:

City

State

ZIP

Student Cell Phone: Parent/Guardian 1:

email

Address (if different) ____________________________________________________________


City State ZIP

Home Phone: ______________________________ Work Phone _____________________ Cell Phone: ________________________________ Email _______________________________ Parent/Guardian 2: ________________________________________________________ Address (if different) ____________________________________________________________

City

State

ZIP

Home Phone: Cell Phone: If unable to reach parent/guardian, please contact

Work Phone Email

Name: ___________________________________________ Relationship: __________________ Home Phone ________________________________ Cell Phone ___________________________ Name: ___________________________________________ Relationship: __________________ Home Phone ________________________________Cell Phone____________________________

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MEDICAL AUTHORIZATION FORM


Student Name as it appears on Passport:
_____________________________________________________________________________ / _______________ Last First Middle Preferred Name
Date of Birth
Please provide copies of insurance cards and make sure your student has a copy

Insurance Company ___________________________________________________________________

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

Parent Name Printed


NOTARY:

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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ACKNOWLEDGEMENT OF RISK AND LIABILITY WAIVER AGREEMENT


As the parent(s) or guardian(s) (hereinafter "the undersigned"), of ___________________________________ (hereinafter "student"), I/we agree to the following understandings: 1. For and in sole consideration of the sum of ten dollars ($10.00), made payable to the undersigned by the released parties, the receipt and sufficiency of which is hereby acknowledged, t he undersigned agree to release, hold harmless, defend and indemnify Chamblee Charter High School, DeKalb County School System, Uwe Neuhaus, and other identified chaperones, individually and in their official capacities (hereinafter "released parties") from any and all claims, demands, rights, liabilities and causes of action arising out of, or in connection with, the personal injury, illness, death or property damage resulting to the student, caused by the negligence of the released parties. The undersigned agree further to release, indemnify, defend and hold harmless the released parties from any damages, claims and lawsuits inuring to the undersigned and resulting from events over which the released parties exercise no control, such as Acts of God, strikes or government restrictions. The undersigned further agree to indemnify, defend and hold harmless the released parties from any claims, liabilities, cost or expenses arising out of personal injury or property damage that the student either causes or contributes to while participating in the exchange between Chamblee Charter High School and Nuremberg-Durer Gymnasium and/or from any financial obligations which the undersigned may incur of the undersigned's behalf. The undersigned acknowledge and agree that the released parties have the right and discretion to make changes to the exchange program to ensure the health, safety, comfort, positive experience and/or convenience of members of the exchange group, whenever in the sole judgment of Uwe Neuhaus and other indentified chaperones, such changes are deemed reasonable and necessary. The undersigned further acknowledge and agree that Uwe Neuhaus and other identified chaperones have the right and discretion to refuse to accept or retain on the Germany exchange trip, any student or person associated with this program either prior to departure or during the course of the exchange visit. The undersigned agree and acknowledge that no responsibility is assumed by the released parties the for loss of passport, airline tickets, or other documents or personal property, or damage to luggage or any personal belongings of the student. It is understood that medical health insurance coverage for the student that is applicable outside of the United States is the responsibility of the undersigned, who expressly accept financial responsibility for any and all medical and/or dental care the student requires during travel associated with the exchange visit. The undersigned agree to provide Uwe Neuhaus and other indentified chaperones with proof of medical health insurance coverage and a Medical Authorization form and assure Uwe Neuhaus and other indentified chaperones that there are no known health related reasons or problems that would preclude or restrict the student's participation in the exchange visit. The undersigned acknowledge and agree that if the student becomes ill or incapacitated during the exchange trip, Uwe Neuhaus and other identified chaperones in their sole discretion, may take such actions as are reasonable and necessary for the student's safety and well-being, including securing medical and/or dental treatment and arranging for the transportation of the student to the student's home at the undersigned's expense. The undersigned agrees to release, defend, hold harmless, and indemnify the released parties from any liability for such action as may be taken on the student's behalf. The chaperones for this exchange trip are Uwe Neuhaus, Lynn Farmer, Brett Belcher. In further consideration for each chaperone's agreement to act as a chaperone for the exchange group during the round trip from Atlanta to Nuremberg and during the time the exchange group spends in Germany, the undersigned hereby agree to release, defend, hold harmless and indemnify the released parties and their heirs, executors and administrators from any and all liability caused by the negligence of the release parties, and do hereby for the undersigned and the undersigned's heirs, executors and administrators waive, release and forever discharge any and all rights and claims for damages as a result of said negligence, which the undersigned or the student may have or which may hereafter accrue arising out of or in connection with his or her capacity as chaperone on the exchange trip to Germany. The undersigned agrees to advance to him/her any defense expenses in any such proceeding initiated by the undersigned. This agreement will be governed by the laws of the State of Georgia . The undersigned hereby declare myself to be physically and mentally sound, and am capable of entering into this agreement. Parent Name Printed Signature of Parent Date

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Parent Name Printed


NOTARY:

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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Student Behavior Contract


As a participant on this trip, it is your responsibility to help make the 2012 exchange trip to Germany a positive and enjoyable experience for yourself, fellow classmates, chaperones, hosting families, and any and all other persons with whom you come into contact during the trip . All participants are expected to demonstrate high standards of conduct and to accept personal responsibility and consequences for their actions. You are expected to exhibit honesty, courtesy, respect and consideration toward all others including, but not limited to: the host families, your chaperones, your classmates as well as anyone else with whom you may come in contact, such as bus drivers, guides, restaurant staff, etc. We expect each student to comply with the following rules of behavior at all times:
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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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10. If the student should violate any of these rules, he/she may be sent home at the sole discretion of

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.

Print student name

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.

Print Parent name

Parent Signature

Date

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