Permission for Medical Care and Release.doc

Permission for Medical Care and Release 未成年人治疗授权确认书 Name of minor 未成年人姓名 Date or last tetanus shot 破伤风注射时间 Medication now being taken 现所服用药物 Reason / 原因 Dosage / 服用量Allergies / 过敏症 Name of insurance company保险公司 ID. or contract number证件号或合同号 Name and phone number of family physician 家庭医生姓名及电话号 We, as the applicant’s parents or legal guardians, agree to authorize STS or the Host Family to act for us in any emergency, accident or illness during the period of time the student is involved in the STS Exchange program. This covers the period from the time the student boards transportation scheduled by the Program until the student leaves the return-scheduled transportation by the Program. 作为申请人的父母或法律监护人，我们同意STS机构或接待家庭在学生接受STS交换项目期间代理我们处理任何的紧急情况、突发事故或疾病。其中，交换项目的期限范围为项目行程的规定时间，即从学生出境时起到学生入境回国为止。 ............................................................................... .......................................................................................... Signature of Father or Legal Guardian Signature of Mother or Legal Guardian 父亲或法律监护人签名 母亲或法律监护人签名 Date ......................... / ................... / ................... 日期 Month Day Year RULES FOR STS STUDENTS 学生准则 1. Respect and uphold your Host Family regulations about curfews, household chores for which you are responsible, smoking and dating. Activities, including inviting guests to the Host Family’s home, must be approved by your Host Family, and they must know where you are, with whom, and when you will return, at all times. 尊重并支持接待家庭对学生宵禁时、所应承担的家务、吸烟及约会的管制。学生的任何活动，包括请人到接待家庭做客，必须经接待家庭的许可。任何时候，学生必须要让接待家庭知道你在哪、和谁在一起，以及何时回来。 2. No drinking of alcoholic beverages including beer or wine. The only exception might be the occasional consumption of wine or beer in the Host Family home with permission of the host parents. 学生不准喝任何带酒精的饮料包括啤酒或红酒。在特殊场合下，学生只有经接待家庭许可，才可以在接待家庭喝啤酒或红酒。 3. No drugs or association with anyone involved with drug