Fillable Permission To Travel Form - Oregon printable pdf download

PERMISSION TO TRAVEL FORM

It is the responsibility of the student to submit this form to their Local Coordinator at least 2 weeks prior to departure.

Incomplete forms will be considered invalid and will not be processed.

Unauthorized travel may result in disciplinary action or possible program termination.

Student’s Name

Host Family Name

Student telephone or email address

Local Coordinator

Destination of trip

Purpose of trip

Trip start date

Trip end date

Mode of Transportation

Will you be missing any school?

If yes, how many days______________

YES

School Approval Granted for missing school

YES

Signature of school official ____________________________________________________________

If traveling outside of the USA: School Official’s signature has been obtained on the 3

page of the I-20 Form

Will you be traveling with your host family?

YES

If you will not be traveling with your host family, complete the information below.

Name of the adult(s) you are staying with

Age

Relationship to student

Destination address

Phone number

List other people you are traveling with

Relationship to student

I authorize my child to travel to the above destination while he/she is a participant in the Private & Public School F-1 Exchange (PSE) Program.

I understand that by giving this authorization during the above period (or until my child is with the host family or PSE representative):



PSE, the host family, and the foreign partner will not be responsible in any way in relation to the child's safety and welfare;



PSE, the host family and the foreign partner will not control the whereabouts of the child;



PSE, the host family and the foreign partner will not necessarily be able to locate the child;



PSE, the host family and the foreign partner will only resume their normal responsibility when the child has returned to the host family;

Travel outside the USA:



If traveling outside the USA, the student is responsible to bring the I-20 form to the appropriate school official to receive permission

of their intent to travel, the duration of their leave, and the date they expect to return to school.



PSE, the host family and the foreign partner cannot guarantee the student will be allowed to re-enter the United States after travel

outside the United States;



In the event the student is detained or deported upon an attempt to re-enter the USA, PSE, the host family and the foreign partner are

not responsible for any additional costs or hardship incurred.

As a parent, I will be liable for any expenses PSE, the host family and our foreign partner may incur to assist my child if necessary.

(1) Host Parent Printed Name:_______________________________ Signature ______________________________ Date: __________

(2) Date Submitted to PSE Main Office:________________________ Approved by: ___________________________ Date: __________

(3) Foreign Partner Name:__________________________________ Signature______________________________ Date: __________

(4) Natural Parent 1 Printed Name:___________________________ Signature ______________________________ Date: __________

Natural Parent 2 Printed Name: ___________________________ Signature ______________________________ Date: __________

PSE  1029 SW Washington Street  Portland, OR 97205  Tel 503-222-9803 or 877-222-9803  Fax 503-227-7224

Permission To Travel Form - Oregon

Related Articles

Related forms

Related Categories