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C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools COMPLETAR Y FIRMAR (AMBOS PADRES) TODAS LA AUTORIZACIONES Y DOCUMENTOS QUE SE INCLUYEN A CONTINUACIÓN.
RECORDAR QUE HAY QUE ADJUNTAR LA COPIA DE LA CARTILLA DE VACUNACIÓN OFICIAL ACTUALIZADA Y DE LA TARJETA DEL SEGURO UNA VEZ COMPLETADAS, DEDEN SER ESCANEADAS Y ENVIADAS A LA COORDINADORA DE INTERCAMBIOS AL MENOS DOS SEMANAS ANTES DE LA REALIZACIÓN DEL INTERCAMBIO Departamento: [email protected] ALUMNOS QUE VIAJEN A ESTADOS UNIDOS: SE OS ENTREGARÁ UNA CARTA EN LA QUE CONSTA QUE EL ALUMNO ESTÁ MATRICULADO EN EL COLEGIO. TAMBIÉN ES IMPRESCINDIBLE LA CARTA DE INVITACIÓN QUE OS MANDARÁ LA FAMILIA DE ACOGIDA.
DEBEIS DECIR QUE ESTÁIS DE VISITA INVITADOS POR LA FAMILIA CORRESPONDIENTE, NO QUE VAIS A ESTUDIAR.
No dudéis en escribirme o llamarme al colegio si surge alguna duda.
C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools Health Information and Consent for Student
ALL requested information must be returned 2
EEKS PRIOR TO ARRIVAL
An official immunization record must be included with this form.
Give details including usual reactions, triggers, treatment and Incluir otra información tal como tipo de reacciones, tratamiento, ALLERGY: Food
ALERGIA: Alimentos
ALLERGY: Bee / Sting
ALERGIA: Avispas/picaduras
ALLERGY: Medication
ALERGIA: Medicamentos
ALLERGY:
Environmental / Seasonal
ALERGIA:
Ambientales o estacionales
ASTHMA
ASMA
OTHER Health Concerns:
OTROS problemas de salud:
MEDICATION
taken daily or routinely
(include reason, dose, frequency)
MEDICACIÓN diaria o de rutina.
(incluir motivo, dosis y frecuencia)
 NO HEALTH CONCERNS OR ALLERGIES (NINGÚN PROBLEMA DE SALUD NI ALERGIAS)
Students must provide and carry emergency medication at all times.
(El alumno debe contar y responsabilizarse de su medicación de emergencia en todo momento.) If necessary the medications listed below may be administered by the school nurse
Si fuera necesario los siguientes medicamentos podrían ser suministrados por la enfermera del colegio:
(please check and complete) □ YES □ NO, do not give medication
Medication Medicamento
For symptoms of
Para los siguientes síntomas
General pain associated with headache, toothache, orthodontics, injury, menstrual cramps, fever of
>100.5
HEALTH INSURANCE INFORMATION
INFORMACIÓN DEL SEGURO MÉDICO
Health Insurance Company and ID #________________________________________(Compañía Aseguradora y Número de la tarjeta.)Student must provide medical coverage insurance policy valid for care in the visiting country. Student must carry insurance card with him/her.
(Todos los estudiantes deben contar con un seguro médico válido en el país de destino y deben llevar su tarjeta correspondiente con ellos.) Parent / Guardian Signature (required) ________________________________Date__________________
Firma del padre o tutor
Medical Provider Signature (required)_______________________________Date____________________
Firma del médico correspondiente
CONSENTIMIENTO
My child_________________________________________, born on_____________________________, permanent resident of _________________________________________________has received a medical exam and is in good health. I give permission for my child to participate in all supervised activities and sports while visiting __________________________ (name of school) (on and off campus). My child is self-directed in matters of health and medication administration. My child will provide all emergency medications she may require and carry them with her at all times. In the event of serious illness or injury my child may receive first aid, medical assessment and care. He/ She may be taken to an emergency department for evaluation including X- Ray and any additional tests required to provide care and treatment. The host parent listed above and / or an adult representative from the __________________________ (name of school) may act on behalf of my child Name_______________________________________________________ Parent / Guardian Signature_________________________________Date________________
Mi hijo/hija ____, con fecha de nacimiento ________, con dirección ___ ha pasado un reconocimiento médico y goza de buena salud. Permito a mi hijo/a a participar en todas las actividades escolares durante su estancia en el ______ (dentro y fuera de las instalaciones del colegio). Mi hijo/a es autónomo en cuestiones de salud así como en la propia administración de medicamentos. Traerá, en su caso, todos los medicamentos que necesita en casos de emergencia y los l evará siempre encima. En caso de enfermedad, lesión grave o accidente mi hijo recibirá asistencia, diagnostico y cuidado médico (incluido el radiodiagnóstico u otro tipo de pruebas que el médico de urgencias considere oportunas). La familia de acogida y/o un representante del colegio del Sagrado Corazón actuarán como representantes de mi hija hasta que me sea notificado lo antes posible. C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools My child,……………………………………………., may participate in the Sacred Heart Exchange program at the Sacred Heart school in …………………………………………… from………………………… to …………………… (exact dates). I permit her to travel by plane, train, bus, taxi, underground, or by whatever other means may be necessary. I understand that he/ she will leave from ………………………. and return to ……………………… upon completion of the Exchange Program. I acknowledge that I am responsible for my child´s safe transportation to and from the host family and while he/she is on the Exchange Program and that I will make arrangement s for his/her return home.
I understand that this is a wholly voluntary and extracurricular activity and that I am under no obligation to complete this agreement.
Release from Liability I am aware that all travel, and particularly travel abroad, which may at times be UNSUPERVISED, can be a dangerous activity involving many risks of serious injury and even death. I understand that although my child´s host family and the Sacred Heart School in Madrid will chaperone him/her, he/she will be UNSEPERVISED at times during his/her participation in the Exchange Program.
I acknowledge that my child must strictly adhere to all School rules and instructions during the Exchange Program and also state that, to the best of my knowledge, my child is in good health and suffers from no disability or condition which renders his/her participation in the Exchange Program medically inadvisable or otherwise limits his/her ability to engage in the activity. I further acknowledge that I must complete the Medical Information and Consent form in order for my child to participate in the Exchange Program. I understand that in the event of a medical emergency, the host -family and Sacred Heart school will abide by the Medical Information and Consent Form on file with the School.
In consideration of the School´s permitting my child to participate in the Exchange Program, I hereby, on behalf of myself, my children, spouse/husband, heirs, agents, executors, administrators, and assigns, release and forever discharge the School, its agents, trustees, officers, and employees, from any and all demands, claims, damages, actions, and causes of action, pertaining to or arising out of my son´s/daughter´s participation in the Exchange Program including, but not limited to, claims for negligence, personal injury, breach of contract, or breach of warranty, except in the event of gross negligence or willful misconduct. I understand that, as a result of my executing this release, I will be forever barred from suing the School as a result of my child´s participation in the Exchange Program.
C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools AUTHORIZATION OF INTERVENTION
IN CASE OF ACCIDENT OR ILLNESS
I, undersigned_________________________________, residing: Home address: ________________________________________ Please, check one or two
authorize the Headmaster/Headmistress/Exchange Coordinator of the hosting
school to follow the medical advice of a doctor in case of accident or
urgent/indispensable
_______________________________born (date) _____________________ during his/her entire stay in the school. authorize the assigned host-parents to follow the medical advice of a doctor
in case of accident or urgent/indispensable intervention for my child
__________________________ born (date) _____________________during
his/her entire stay in the family.
request to be called immediately before any decision is made regarding my child’s health: Parents/Guardian’s signature :_____________________________
Date:__________
C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools AUTHORIZATION FOR LOCAL TRANSPORTATION AND TRAVEL
To whom it may concern (host parents, faculty, administration of schools): I authorize my child__________________________to participate in outings / field trips / travels organized by the school or by my child’s host family.
I authorize him/her to leave the school or arrive at school after or before school hours: only with an adult or with a friend or a classmate but not by Parent’s/Guardian’s signature(s):
____________________________________________________________ Date :__________
Student’s signature :__________________________
Date :__________
C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools Nombre y apellidos del alumno: _____________________________________ Nombre de la madre: ________________________________________(please print) (Mother´s name)Teléfono particular y/o móvil: e-mail: ____________________________________________________ Nombre del padre: ________________________________________(please print)(Father´s name)Teléfonos particular y/o móvil: e-mail: ____________________________________________________ En caso de que no fuera posible contactar con los padres, por favor contacte con una de estas personas:If parents cannot be reached please contact: Nombre y apellidos:_______________________________ (please print)NameTeléfonos: ____________________ - _____________Phone numberse-mail: ____________________________________________________ Nombre y apellidos:_______________________________ (please print) NameTeléfonos: ____________________ - _____________ e-mail: ____________________________________________________ C/ FERRAZ, 63 28008 MADRID Sacred Heart Schools Transportation information:
Name of student: ______________________________________________________ Sacred Heart School: ___________________________________________________ Means of transportation: ________________________________________________ Please e-mail Marta Núñez ([email protected]) your itinerary,
and print out it and attach.
Spanish passport nº _____________, issued in _________(city), _________(country), on ________________ (date), 20__ and valid until ____________, 20___,(Remember your passport has to be still valid 6 months after the date of your return).
Name of Parent/Guardian_________________________________________(please print) Signature of Parent/Guardian ____________________ Date ___________

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