PERMISSION FORM FOR TRAVEL

OUTSIDE OF DISTRICT
4195 TRAVELING WITH
HOST FAMILY
Kairos Luis De Frana Lara
From the Host Parents of Inbound
Student:

have invited him/her to travel with us outside of District 4195. Also declare that we assume
all the expenses of this
trip and exempt District 4195 from any liability with respect to this trip, which it is
assumed entirely by us. However, we undertake to inform the District 4195 of any

Travel information:
Motive:Travel
29/12/2015
Between (DD/MM/YYYY):
and 4/01/2016
Oaxaca
de
Jurez/
Mxico
From (City/Country):
to: Guadalajara/ Mxico
Conveyance (bus / plane / Plane
car):
Place where will be staying: Own or
Hotel
Other:
Relatives
Home
Full address
on this travel: (Street, number, city, state/province/department, zip code,
telephone number):

Between (DD/MM/YYYY):
and
From (City/Country):
to:
Conveyance (bus / plane / car):
Place where will be staying: Own or
Hotel
Other:
Relatives
Home
Full
address
on this travel: (Street, number, city, state/province/department, zip code,
telephone number):

Between (DD/MM/YYYY):
and
From (City/Country):
to:
Conveyance (bus / plane / car):
_
Place where will be staying: Own or
Hotel
Other:
Relatives
Home
Full address
on this travel: (Street, number, city, state/province/department, zip code,
telephone number):

Host Parents Full name:

Father: Rodolfo Carlos Ruiz Silva

Signature:

Mother: Angelita Lpez Carrillo

Signature:

Date:22/12/2015

(*) We agree to this travel: (name, date and signature)

Sponsor Rotary Club:
Sponsor Rotary District Chairman:
Club Rotario Oaxaca
Host Rotary Club:
Gerardo Corres
Zone Co-Chair:
Cap. Jose Alvarez
Host District Chairman:

(*) All signatures are needed in order

to travel