2014 BHS-Mexico Trip

Checklist of Forms

______Payment Schedule (check off payment:

#1 ______(November 05, 2013) ($800)

#2 ______(November 19, 2013) ($675)

#3______(December 03, 2013) ($675)

______3 copies of U.S. passport or equivalent from different country

_____NOTARIZED Letter(s) of Permission for student under 18 years of age to travel to Mexico. May be one letter signed & notarized by both parents OR a notarized letter from each parent. If parent is deceased, student must travel with official death certificate.

______Out-of-Country Student Information Sheet

______Health Information Sheet for Field Trips

______Medical Release Form

______Medical Insurance and Care Addendum

______Explicit Guidelines for Students

______Student & Family Contract

______Teacher Approval Form – Student needs all teacher signatures

AUTHORIZATION TO LEAVE THE COUNTRY

To the Required Authorities:

I/We, the undersigned parents of the minor listed below, hereby grant permission to

Ric Calleja

Agnès ALBEROLA and of Brookline High School, Massachusetts

Pedro Mendez

to travel with our son/daughter out of the United States in to MEXICO during:

15thof FEBRUARY to 1st of MARCH, 2014

Furthermore, we authorize these adult chaperones to seek the necessary care should child experience any illness or accident.

CHILD TRAVELING ABROAD

Name: DOB:

___ MOTHER ___ FATHER___ LEGAL GUARDIAN

Parent/Guardian Name:
Address / City/State/Zip
Home Phone / Work/Cell Phone
Signature of Parent/Legal Guardian

___ MOTHER ___ FATHER___ LEGAL GUARDIAN

Parent/Guardian Name:
Address / City/State/Zip
Home Phone / Work/Cell Phone
Signature of Parent/Legal Guardian

For Notary Use

County of :
State of:
On ______(date), ______appeared before me and signed the above document.

Out-of-State and International Travel Consent Form and Release of Liability

I, ______, wish to participate in a Brookline Public Schools sponsored exchange trip to Cuernavaca, Mexico on or about February 15 to March, 01 2014. I understand that Pedro Méndez Barroso, Ricardo Calleja, Agnes Alberola (hereinafter, the “trip leaders/chaperones”), all of whom are currently teachers at Brookline High School, will accompany the group on the trip.

In consideration of the educational value of travel in foreign lands or to other states and the other privileges and advantages to be gained by my participation in such exchange, the value of which I hereby acknowledge, I do hereby forever release, acquit, discharge and covenant to hold harmless the Town of Brookline, its departments, officers, employees, agents, and representatives, including, but not limited to the trip leaders/chaperones (hereinafter, the “Releasees”), of and from any and all actions, causes of actions, claims, demands, damages, loss of services, expenses and compensation on account of, or in any way arising from, directly or indirectly, all known and unknown personal injuries or property damage which I may now or hereafter have, resulting or to result from my participation in the said trip. I further agree to indemnify and hold forever harmless the said Releasees against any loss, damages or costs, or attorneys fees, that said Releasees may be compelled to pay on account of any injury or damage or any other reason on my behalf while participating in said trip.

I further agree that should I behave in a manner which in the sole judgment of the trip leader(s)/chaperone(s) endangers my own health, safety or welfare, or the health safety or welfare of others in the group, including, but not limited to, any infraction of the prohibitions against drugs and/or alcohol, then, the trip leaders/chaperones, in their sole discretion, have my express permission and consent to secure a seat for me on the next available flight returning to Boston, Massachusetts, at my expense.

I further acknowledge and understand that I may have a certain amount of time each day when I may not be in the presence of a trip leader/chaperone. I agree that on those occasions, I am capable of, and shall be responsible for, managing time spent on my own in accordance with the trip’s schedule of activities.

I finally acknowledge and understand that the Brookline School Committee and/or the Superintendent of Schools, in its/his sole discretion, reserve the right to cancel this trip (up to and including on the day of departure), and that I will be responsible for any monies already paid toward this trip. Copies of any relevant State Department advisories will be provided to me.

______

Signature of StudentDate

______

Signature of Parent/GuardianDate

THE PUBLIC SCHOOLS OF BROOKLINE

Health Information Sheet for Field Trips

To be carried on trip by all chaperones.

Name of Student: ______Date of Birth: ______

Home Address: ______

StreetCity & StateZip

Parent/Guardian Name:______

Home Address: ______

StreetCity & StateZip

Primary phone number:______Secondary phone number: ______

Email: ______

Primary Care Doctor: ______

Contact Number: ______

Insurance Information: ______

(Group and Plan Number)

I have verified overseas coverage for my child: YES NO

1. Any food or drug allergy? _____ If yes, what? ______

2. Allergy to bee sting or insect? _____ If yes, does child know how to administer epipen? _____

3. Other allergies: ______

4. Has your child been exposed to any communicable diseases within the last 21 days? ______

If yes, what? ______

5. Does your child have any chronic medical problem other than allergies (i.e. asthma)? If yes, please specify: ______

6. Is your child bringing medication? ______If yes, what? ______

Reason for taking: ______Should it be refrigerated? ______

Complete instructions for administration: ______

______

7. Any other medical concerns? ______

PARENT AUTHORIZATION

I certify that the information below is correct and true to the best of my knowledge.

______

Parent/Guardian SignatureDate

PERMISSION TO TREAT

I understand every effort will be made to contact parents or guardian of student. In the event I cannot be reached, I hereby give permission to the physician selected by the director(s) in charge of the field trip to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for child as named above.

______

Parent/Guardian SignatureDate

SCHOOL TRAVEL RELEASE

MEDICAL INSURANCE AND CARE ADDENDUM

PERMISSION TO TREAT

I/we recognize that medical treatment on an emergency basis may be necessary at a time when I/we are not able/available to give my/our consent in advance of such emergency care, and I/we hereby give consent to the trip chaperones and/or host family to authorize such care as may be deemed necessary under existing circumstances.

I/we also agree to purchase and/or maintain medical insurance covering accidental injury, dismemberment, and/or death for the duration of the trip

______

Student SignatureDate

______

Parent SignatureDate

______

Name of Sponsoring School/Destination

Date of Departure______

Date of Return______

EXPLICIT WRITTEN GUIDELINES FOR STUDENTS

2014 Brookline High School – Mexico Trip

Students participating in the 2014 Mexico trip will abide by Brookline High School rules and regulations as stated in the Handbook, as well as those enumerated in this document.

  1. Students and parents/guardians will agree to and sign the rules explained in the STUDENT CONTRACT (see attached).
  1. Students and parents/guardians will agree to and sign the information and rules explained in the HEALTH INFORMATION SHEET FOR FIELD TRIPS (see attached). Students on medication must be able to self-medicate or give early notification if a parent/guardian must accompany the trip.
  1. Parents/guardians must agree to and sign the information explained in the OUT-OF-STATE AND INTERNATIONAL TRAVEL CONSENT FORM AND RELEASE OF LIABILITY (see attached).
  1. Students must be in good academic standing to participate in the program.
  1. Students must be aware of and follow airport and terminal procedures.
  1. Students are responsible for their own spending money. Chaperones will be responsible for the group expenses.
  1. Students are responsible for acquiring or renewing their own passports. They must make three copies of their passport and give them to the Chaperones.
  1. Students must honor all deadlines and attend all student and parent/student meetings.

In addition, the School Committee and the Superintendent may cancel a trip at any time, including up to the day of departure.

I, (print name) ______, have read the packet and agree to the information listed above.

Student Signature ______Date ______

Parent Signature ______Date ______

Student & Family Contract: 2014 Mexico Trip

BROOKLINE HIGH SCHOOL, BROOKLINE, MA 02445

CODE OF CONDUCT:

  1. I agree that while I am traveling with the Brookline High School Mexico Trip, I will not use or possess alcohol or controlled substances as defined in G.L. c. 94C.
  1. I agree to abide by the curfew as set by the chaperones and the Cuahnáhuac School. At the appointed time, I will return to my host family’s house. House calls will occur after curfew to ensure that the students are where they are supposed to be.
  1. I agree to uphold all laws and regulations as dictated by local, State and Federal governments (i.e. under age drinking, assault, shoplifting). I agree to respect the property of others and to pay for any losses and/or damages for which I am found responsible.
  1. I agree to the requirements for traveling with a large group, such as meeting times and not traveling alone. Should I be without the presence of a teacher/chaperone/host parent, I will be accompanied by at least 2 other students.
  1. I understand that Mexicans do not use the telephone much past getting the message across. My host family’s phone is strictly off limits for making any long distance calls, even if they’re collect or if I am using a calling card. (There are service fees for all these services.) I will make every effort to call and receive calls at the school or using a pay phone in my neighborhood.
  1. I understand that I am under the direct responsibility and authority of the assigned chaperones, Pedro Méndez, Ricardo Calleja and Agnes Alberola; and I will follow and abide by any rules and/or decisions made by these persons.

I am signing this Contract, and hereby giving my word of honor that I will follow the above Code of Conduct while traveling to, from, and in Mexico. As a representative of Brookline High School, I understand that my behavior is critical to the success of the trip and sets a precedent for future trips. Any violation of these rules will result in disciplinary action, including but not limited to: being sent back to the United States at my parent’s expense, or being suspended from performance, sports teams, or other activities.

Student signature ______Date ______

I have read and agree to the above Contract. I promise to assist my child and the teacher-chaperones in abiding by and enforcing the stated parameters.

Parent/Guardian Signature ______Date______

BROOKLINE HIGH SCHOOL

TEACHER APPROVAL FORM: TRIP TO MEXICO

Dear Teacher,

With your permission, ______will go on a two-week trip to Cuernavaca, Mexico. We will leave February 15 and return March 01, 2014. Therefore, this student will miss four of your classes the week AFTER February vacation. During this time, she/he will spend six hours each day in intensive Spanish classes, will engage in cultural exchange activities, and will live with a Mexican family.

Students understand that they are expected to make up all work which they miss during the week of February 24-28. We request that you either give the student work to take with her/him, or set a deadline by which time all work must be completed and handed in. We are also happy to administer tests and quizzes while in Mexico.

Please sign below, indicating your approval or disapproval of this student’s participation in the Mexico Trip. Please make sure to comment if the student is currently earning a D or an E in your class. Also, indicate in the space provided if you will contact us via email with your concerns or words of support.

We appreciate your cooperation and support of this learning opportunity for our students. We hope ______’s participation creates a minimum of disruption for you and your class.

Sincerely,

Pedro Méndez, Ricardo Calleja, Agnes Alberola

ApproveDisapproveComments

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Top of Form

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