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Cornerstone Student Travel Request Form
栋梁学生出行申请表
*All parents must have written permission in wechat group to permit this trip
(*家长务必在微信群中书面同意学生下面的出行申请)
Student's name
*
Student Email
*
Student's Cell Phone Number
*
Reason for the Trip
*
个人平时出游
感恩节个人出游
春假个人出游
寒假个人出游
寒假回国休假*
暑假回国休假*
1.Travel Transportation Information- Departure
Please indicate how and when the student will be departing
Transportation 交通方式
*
Flight
Bus
Car
Leave Chicago Date 离开芝加哥时间
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Flight/Train/Bus Number 航班号信息
*
Destination
*
2. Travel Transportation Information- Return
Please indicate how and when the student will be returning
Transportation 交通方式
*
Flight
Bus
Car
Arrive Chicago Date 抵达芝加哥时间
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Flight/Train/Bus Number 航班信息
*
3.Travel Contact Information
如果学生是回国探亲,则不需要填写下面部分。
Who will you stay with?
Address of where the student will be staying
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4. Transportation
By signing below you acknowledge and accept transportation will not be provided by Cornerstone Inc. itself. Responsibility of all occurrences is solely on that of the student and his or her own parents. 栋梁教育将为寒暑假回国探亲的同学提供机场接送机,其他情况的个人出游,请自行解决安全方式,并通知报备栋梁老师。谢谢理解和支持。
5. Lodging
Students and parents are solely responsible for making all arrangements for student's independent travel. Cornerstone Education will not be held liable for anything involving accommodations outside of the student's stay away from Cornerstone Education Inc.
6. Requirements
Families must notify Cornerstone Education Inc. of any changes in travel, and must submit at travel consent form any time his or her student is traveling independently.
7. Consent
I hereby attest that I am (we are) the legal parent/guardian(s) of the above-named child and hereby consent to the child's participation in the activities described above. I/We warrant that I/We have full authority to legally consent to my child's participation in the activities described on this form, and all provisions described therein. I understand that activities of the kind described above may result in injuries to my child but nonetheless specifically request that he or she be allowed to participate in those activities.
8. Emergencies
If the above-named child requires any emergency medical treatment or procedures during the activities, I/we hereby consent to Cornerstone Education Inc. being called at (773) 242-3278 and arranging for or consenting to such procedures or treatments. For purposes of such procedures and/or treatments, my/our child's blood type, allergies, or other medical problems, if any, are listed above.
13. Release and Indemnification
I/We release and waive, and further agree to indemnify, hold harmless or reimburse Cornerstone Education Inc. the individual members, agents, directors, officers, employees, volunteers, and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for an losses (including attorney fees incurred by Cornerstone Education Inc. or any of its individual employees, agents, volunteers, etc in enforcing this indemnity provision) without limitation in time or amount, damages or injuries arising out of, during, or in connection with my/our child's participation in the activities, the traveling to and there from, and the rendering of emergency medical procedures or treatment, if any. I/We understand that this release and indemnification shall survive the end of my/our child's participation in the activities referenced on this form and shall have no limitation in time or amount.
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