Permission for Independent International Student Travel

Child Name (from passport):__Zhang, San_______________________ （孩子名字）

I hereby authorize my child to travel unaccompanied by an adult on the following itinerary:
Destination: __Maplewood_________________________________ （到达的美国城市）
Planned Activities:______Study in an American high school_______
Method of Transportation:_____By plane_____________________
Purpose of Travel:____Study___________________________
Itinerary (include flight/train/bus itinerary, hotel address, booking confirmation etc. if
applicable):
___Flight No.:___CA8808_____________________________________________ （航班号）
___School Address:___ 2625 Larpenteur Ave E, Maplewood, MN 55109 （学校地址）
__________________________________________________________________

Parent/Guardian 1 Contact Information: （父母或监护人联系方式）

Name:____ Zhang, Ming_____________________________ 姓名
National ID No.:__110105197304110988________________ 身份证号
Occupation: _ Software Engineer_____________________ 职业
Relation to the student: Father______________________ 和孩子的关系
Cell Phone Number:___+8618500199999________________ 电话
Email:___zhangming@163.com________________________ 电子邮箱

Parent/Guardian 2 Contact Information: （父母或监护人联系方式）

Name: LI, Xi____________________________________ 姓名
National ID No.:__110109197909094108_______________ 身份证号
Occupation: ___Nurse______________________________ 职业
Relation to the student: ___Mother____________________ 和孩子的关系
Cell Phone Number:___ +8618500178888_______________ 电话
Email:__ _ lixi001@163.com_______________________ 电子邮箱

Assumption of Risk: I hereby knowingly, expressly and specifically assume all risk and
responsibility for the student’s health, safety, and property, including but not limited to bodily
injury, death, emotion, trauma, property damage, inconvenience and/or loss resulting from the
student’s participation in these activities. It is my intention fully to assume all of the risks of
travel for the student.

I understand that my child’s travel is at his/her(去掉一个) own risk. （下方两处父母/监护人签

字/时间）

Parent/Guardian Signature 1: ________________________ Date:__________________

Parent/Guardian Signature 2:_________________________ Date:__________________