SOUTH CENTRAL AMBASSADOR TOURS, INC.

PARENTAL CONSENT, DISCLAIMER AND RELEASE FORM

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This signed document must be submitted to complete every student’s reservation. While scanned electronic copies are preferable, we will accept faxed copies if legible. This parental consent form requires signatures by both of the natural parents or legal guardian unless they are divorced, legally separated or one is deceased (please indicate if that is the case).


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Student’s First Name: ________________________   Last Name: ____________________________________________


Home Country: ______________________      Male _____   Female _____ Birth date (MM/DD/YY):_________________


Host Parents: _________________________________________________ Telephone: (______) _______-____________


Host Parent’s Address: _______________________________________________________________________________


Host Parent’s City: _____________________________________ State: ________ Zip Code: _______________________


STUDENTS ARE REQUIRED TO CARRY THE LEVEL OF HEALTH INSURANCE COVERAGE AS IS MANDATED BY ROTARY INTERNATIONAL’S YOUTH EXCHANGE PROGRAM. WE DO NOT ACCEPT INSURANCE WRITTIN IN THE STUDENT’S HOME COUNTRY AS IT IS OFTEN REFUSED BY THE MEDICAL COMMUNITY WHEN THEY ARE AWAY FROM THEIR HOSTING CITY. STUDENT’S MUST HAVE THEIR INSURANCE CARD IN THEIR POSSESSION AT ALL TIMES WHEN TRAVELING ON TOUR.


     We give permission for emergency and regular medical care and treatment; including but not limited to major emergency procedures, administration of anesthesia, or blood transfusion for urgent treatment of any illness or injury, which a qualified medical practitioner may deem necessary. We specifically assign to the Director or Staff member of the Tour the legal right to sign all medical emergency release documents both for doctors and for hospitals on behalf of our child/ward. We further authorize these individuals to serve as my child’s Personal Representative for Health Insurance Portability and Accountability Act (HIPAA) for the purpose of receiving medical information and communicating with medical providers about my child’s medical condition.

     It is understood and agreed by the parents (natural and host) and by the student that South Central Ambassador Tours, Inc. and all Tour staff (et al) are hereby expressly released from any and all liability, for any property damage or loss, injury or death, which the student might suffer while taking part in the tour, both as to any right or actions that might occur to the student or the parents of the student, the heirs, executors, administrators or assigns. The undersigned parents further agree, to indemnify and save harmless South Central Ambassador Tours, Inc. and all Tour staff (et al) from any and all claims and cost, including but not limited to counsel fees and costs that may arise from any injury, death or damage to any student while on the tour. This paragraph is to be construed under the laws of the State of Kansas, the site of the Charter of South Central Ambassador Tours, Inc.



Natural Father: ______________________________________________________________________________________

                           (name printed)                                                 (signature)                                                             (date)


Natural Mother: _____________________________________________________________________________________

                           (name printed)                                                 (signature)                                                             (date)




CONSUMER DISCLAIMER NOTICE: The issuance of any tickets, reservations, or bookings by South Central Ambassador Tours, Inc. is done on the express condition that: 1) South Central Ambassador Tours, Inc. shall not be responsible for any changes in fares, rates, charges, or prices initiated by the carrier(s) or suppliers(s) of services, and 2) South Central Ambassador Tours, Inc. shall not be responsible for any damages resulting from cancellations, changes, or disruption of any services and/or for refunds of monies already paid or transmitted to any carrier or supplier of services. Customer’s initial retention of tickets, reservations, or bookings after issuance shall constitute consent by customer, on his/her behalf and on behalf of his/her companions, to the above. South Central Ambassador Tours, Inc. does not guarantee, and shall not be responsible for, any bookings or reservations made or confirmed by agent to the customer in the event that the original itinerary has been changed pursuant to the customer’s request. Nothing agreed to herein by the customer is meant to interfere with customer’s legal rights against any carrier(s) or supplier(s) of services. South Central Ambassador Tours, Inc. and their representatives act only as agents for the traveler in making arrangements for hotels, transportation, sightseeing, restaurants or any other services in connection with the itinerary for the individual traveler who, by acceptance thereof, agrees that South Central Ambassador Tours, Inc. and/or their agents and suppliers shall not be liable for any injury, damage, loss, accident, liability, delay or expense to person or property because of any acts of war or terrorism, any act of default of any hotel, carrier, restaurant, company or person rendering any of the services included in the itinerary or during the trip. The tickets, coupons, tariffs, rules or contracts currently in use by any contractor rendering services shall constitute the sole contract between such contractor and the traveler. South Central Ambassador Tours, Inc. accepts no responsibility for any damage or delay due to sickness, pilferage, labor disputes, machinery breakdown, quarantine, government restraints, weather or any other cause beyond their personal control. No carrier shall be responsible for any act, omission or event during the time passengers are not on board its own conveyance. The right is reserved to cancel or change itineraries, or substitute services without notice and to decline to accept or retain any passenger at any time as my be necessary for the proper handling of any tour.

Revised August 2009