1/1 We, (legal guardian`s names) do solemnly declare: 1) We are t

We, ____________________________________________________________ (legal guardian’s names)
do solemnly declare:
1) We are the parents / guardians of:
a. Name: __________________________________
b. Birthdate: _______________________________
c. Place of birth: ____________________________
d. Passport or ID number: _____________________
2) We have joint legal custody of the child.
3) The child is travelling with lecturers ______________________________________________ (names)
with our full knowledge and consent, for the purposes of a trip from _____________________ (your
city), ________________________ (your country) to Olomouc-Radikov, Czech Republic for the
“Verbattle meets Europe: The Continuation” International Youth Exchange organized by the Czech
Debate Society under the Erasmus+ programme of the European Union.
4) This trip will commence on or about 10/01/2016 (m/d/y) and end on or about 10/08/2016.
5) We appoint aforementioned leaders as the child’s guardian for the purposes of consenting to
emergency medical procedures during the trip.
6) If there are any questions regarding this document, we the undersigned, can be reached via telephone
at ___________________________ (your phone number)
AND we make this solemn declaration, conscientiously believing it to be true and knowing that it is of the
same force and effect as if made under oath.
Signatures:
_____________________________________
_____________________________________
Heart of Europe · Olomouc Open Cup · školení · programy pro sociálně znevýhodněné · jazykové tábory
Česká debatní společnost, z. s., Tomkova 314/45, Olomouc, 77900 | IČ 26656817 | www.c-d-s.cz
Od 1. 1. 2014 spolek zapsán ve spolkovém rejstříku, s. z. L 6268 vedená u Krajského soudu v Ostravě.
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