Inbound Permission To Travel Form (Page 2 of 2) in pdf

Inbound Permission To Travel Form Page 2

If the student will be traveling outside the United States:

Country: __________________________

Does the country admit persons from the student’s home country?

______Yes

_____No

Does the country require a visa for persons from student’s home country

______Yes

_____No

If yes, does the student have the appropriate visa?

______Yes

_____No

Date passport expires: _______________ USA visa is multiple entries and is valid until: ____________

USA documents stapled to student’s passport:

________IAP66 or DS-2019 ______ I94

If not traveling with host parents (must be approved by host Youth Exchange Officer and YEX

Committee)

If this is a sponsored trip, name of sponsoring group: ________________________________________

Name of adult chaperone with whom student will travel: _____________________________________

Name of adult chaperone with whom student will stay: ______________________________________

Relationship of adult chaperone to host family or student: ____________________________________

(Background checks may be required)

Approvals

Host Father’s signature ________________________________________________________________

Host Mother’s signature ________________________________________________________________

Youth Exchange Officer signature ________________________________________________________

District YEX Committee Representative ___________________________________________________

Permission of Natural Parents, if Needed (Permission may also be given via e-mail)

Student’s Father’s Signature ___________________________________________________________

Student’s Mother’s Signature __________________________________________________________

Page 2 of 2

Revised 8/2012

Inbound Permission To Travel Form Page 2