Travel Authorization

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Your information

RMRYE Travel Authorization

Requests for Travel outside of Colorado MUST be APPROVED prior to purchasing tickets. Travel OUTSIDE OF US requires that your DS2019 be brought to the Responsible or Alternate Responsible Officer for additional signatures. You may be DENIED entry to US if your DS2019 is not countersigned.

Student First Name *

Student Last Name *

Student Phone *

Student Email *

Home Country *

Natural Parent Name *

Natural Parent Email *

Host Rotary Club *

Rotary Counselor Name *

Rotary Counselor Email *

Current Host Family *

Host Family Cell # *

Host Family Email *

Today's Date *

Travel Start Date *

Travel End Date *

State(s) or Country you are visiting *

Describe your trip - places you'll stay, with whom, mode(s) of transportation, etc. *

Will you travel with your host family? *

Yes

No - if no, explain below

I am NOT traveling with host family. I am traveling with:

Will you be missing School? *

Yes - Provide School Counselor contact information

School Counselor Name

School Counselor Phone

School Counselor Email

NEXT STEPS: An email will be sent to your host parents, natural parents, Club Counselor. Asking them to each approve the requested travel. Trips during school will result in a call and email to the counselor information provided. Once confirmations have been received back from each party a decision about your trip request will be sent and, if approved, tickets and other logistics may be confirmed.

SMS/MMS

By checking this checkbox, you understand this is a binding signature and is a legal indicator of your consent. Thank you!

I consent to E-sign this document and authorize this trip.

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