E
C
LEMENTARY
AMPUS
!
1616 West Street
Woodland CA 95695
G
UARDIANSHIP
!
Phone 530.666.6615
Fax 530.666.3470
M
&
H
S
C
IDDLE
IGH
CHOOL
AMPUS
A
UTHORIZATION
WOODLAND
CHRISTIAN
!
1787 Matmor Road
Woodland CA 95776
!
Phone 530.406.8800
Fax 530.406.0900
F
ORM
1974
EST.
Please f ill i n a ll b lanks ( including p hone n umbers a nd e mail a ddresses) b elow, a nd h ave L EGALLY NOTARIZED:
We, _ _________________________________________________ & _ _________________________________________________,
Print F ather’s F ull L egal N ame
Print M other’s F ull L egal N ame
parents o f _ ____________________________________________, _ ___________________ g ive L imited P ower o f A ttorney f or
Print M inor’s F ull L egal N ame
Birth D ate
Legal G uardianship o f t his c hild t o _ ___________________________________ & _ _______________________________________.
Legal G uardian(s)’s F ull L egal N ame
Legal G uardian(s)’s F ull L egal N ame(s)
Parent’s F oreign A ddress
City:
Province T erritory:
Postal C ode:
Country:
Fathers P hone:
Mothers P hone:
Fathers E mail:
Mothers E mail:
We, t he p arents, h ave c onsulted w ith t his p erson(s) a nd t hey h ave a greed t o s erve a s L egal G uardian. I f at any time this person(s) is no longer able
or willing to be the Legal Guardian, we agree to find new a Legal Guardian and complete a new Guardianship Authorization Form, have it
notarized and submitted to Woodland Christian School immediately.
We u nderstand t hat: i t is a requirement that all students at Woodland Christian School must live with an adult at all times. I f a t a ny t ime t he
legal g uardian, d esignated a bove, i s o ut o f t he i mmediate a rea m ore t han 2 4 h ours, t he s chool o ffice m ust b e n otified i mmediately w ith t he n ame
and n umbers o f a s ubstitute c are g iver w ho h as a lso b een g iven p ower o f a ttorney b y t he p arents. I u nderstand t hat I m ust n otify t he s chool o ffice
immediately i f t here i s a ny c hange i n A NY o f t his i nformation.
FAILURE TO COMPLY WITH ANY OF THE ABOVE MENTIONED CONDITIONS MAY RESULT IN STUDENT’S EXPULSION AND TERMINATION OF I-‐20.
☐
☐
U .S. Citizen
P ermanent Resident (green card)
Guardian is:
Male G uardian:
Female G uardian:
California A ddress:
California A ddress:
City:
State
Z ip
City:
State
Z ip
Home P hone:
Home P hone:
Cell P hone:
Cell P hone:
Work P hone:
Work P hone:
Email:
Email:
Host Family – if student lives away from Guardian, please complete:
Home S tay M ale G uardian:
Home S tay F emale G uardian:
California A ddress:
California A ddress:
City:
State
Z ip
City:
State
Z ip
Home P hone:
Home P hone:
Cell P hone:
Cell P hone:
Work P hone:
Work P hone:
Email:
Email:
This document must be signed by PARENTS, in the presence of a LEGAL NOTARY:
Birth P arent S ignature: _ __________________________________ D ate _ ________________
Notary S ignature________________________________________ D ate _ ________________
Notary S tamp
Rev 12/2014
1