CCI Greenhea Trave Reque Form G art el est m

U.S.

Internatio onal

Only completed forms with all signatures will be considere This form is required for all students wishin to travel w ed. ng ally osts or anywhere without their hosts. For dome e h estic and interna ational travel, th CCI Greenhe he eart internationa with their ho Chicago Of ffice must receiv this complete form at least 2 weeks prior to travel. For inte ve ed o ernational trave the CCI Greenheart el, Chicago Of ffice must receiv this form and the DS-2019 at least 3 weeks in advance. It i the students responsibility to ve d a is s y find out if there is any ad t dditional docum mentation (i.e. visas or other travel forms) n v necessary to tr ravel to their destination and that their U.S. visa allow for multiple entries into th U.S. Do not confirm or pay f any travel n r ws e he for arrangemen without rece nts eiving signed ap pproval from the CCI Greenhea rt Chicago Offic If approved and travel chan ce. nges, please notif office immediately. fy
__________ __________ Student Firs name st ____________ __________ Student Last name n _____________ __________ Country _ ______________ ______________ ______ T Travel dates mm/ /dd/yyyy to mm/d dd/yyyy Hosts Sc chool Self Ot ther

from______ ______________ _____________ to ____________ t _____________ ___________ wi th: (C City, State, Coun ntry) (City, Stat Country) te,

Student will be staying with: _____________ ______________ ______________ ______________ ______________ ______________ ______ Name of Resp ponsible Adult H His/Her Relations ship to Student at: Home of Responsible Adult A Hotel/Re esort/Other:____ ______________ _ __________ ______________ ______________ ______ Phone Num mber __________ ______________ ______________ ______ Alternate Ph hone Number

__________ ______________ ______________ ______________ _____________ _ Address City y State Zip Travel by me eans of (check all that apply): a car c plane tra ain bus

PLANNED ITINERARY: Document(s) with itinerary details attached; ____p page(s) Outgoing: Flight/bus/tra number: ____ ain _____________ ______________ _ Flight t/bus/train numbe ___________ er: ______________ _____ Carrier/Com mpany: ________ ______________ ______________ _ Carrie er/Company: ___ ______________ ______________ _____ Transit Date ___________ es: ______________ ______________ _ Trans Dates: ______ sit ______________ ______________ _____ Return: Flight/bus/tra number: ____ ain _____________ ______________ _ Flight t/bus/train numbe ___________ er: ______________ _____ Carrier/Com mpany: ________ ______________ ______________ _ Carrie er/Company: ___ ______________ ______________ _____ Transit Date ___________ es: ______________ ______________ _ Trans Dates: ______ sit ______________ ______________ _____ dult must sign the following: I/ t /We hereby requ est that the abov ve-named studen be permitted: nt NOTE: The Responsible Ad to visit or to travel with me/us on the da ates and via the it tinerary listed ab bove. I/we agree to contact CCI G e Greenheart at T: 1 (800) 63 34-4771 regardin any emergenc situations or changes of itinera and/or contac information. ng cy c ary ct __________ ______________ ______________ ______________ ______________ ______________ ______________ ________ Responsibl Adult Signatu le ure D Date

CCI Greenh heart LOCAL CO OORDINATOR I confirm tha the host family of the above na at y amed student, ag gree to allow their host son/daugh to participate in the travel list r hter e ted above. If the travel occurs while school is in session, I confirmed with ______ e w ______________ ______________ ____________ th the hat Name of school officia and title e al above name student be exc ed cused from class to take part in the travel abov The student a ses n ve. agreed to make u missed coursework. up I have no ob bjections to the students participa ation in the trave listed above. el __________ ______________ ______________ ______________ ______________ ______________ ______________ ________ LC Signature D Date P NATURAL PARENTS: Travel permission form sig gned in applicatio (signatures no required below on ot w) OR arents of the abo ______________ ______________ ______________ ______________ ___________, pa ove-named stude ent, We, ______ agree to allo our son/daugh to participate in the travel list above. We fu ow hter e ted urther agree to h hold harmless the Center for Cultural e Interchange, its staff, its hosts, its representa atives and its par rtner organization for our son/da ns aughters welfare and assume al e, ll g ments, lodging an meals, superv nd vision, and any a all costs asso and ociated responsibility for his/her well-being, including travel arrangem with travel. We release the Center for Cultura Interchange, it staff, its hosts, its representativ and its partner organizations from W C al ts , ves s any respons sibility or liability during our childs participation in the travel listed above. We furth er recognize tha the health and d s at accident insurance provided may not be valid for any travel outside of the Un ited States, and that any time tha a student trave d o at els outside the U.S., he/she may experience gre difficulty re-en d U y eat ntering the United States to comp plete the Program m. __________ ______________ ______________ ______________ ______________ ______________ ______________ ________ Natural Par rent Signature D Date RD/RM Approved De enied PM and Datte approved: ______ ________________ ________

CCI Greenheart (AYP De ept.), 712 N. Wells St., Chicago, IL 60654 T W TEL: (800) 634-4771 FAX: (31 944-0713 12)