CHILD TRAVEL CONSENT FORM

State of Oregon

For the health and safety of your child, Open Space Dance will be providing an Adult Chaperone to accompany your child/minor, during their stay at Portland State University. We ask that all Parent/Guardian's of minors attending Space Camp I and staying at Broadway Hall (PSU Residence Campus) fill out this form giving consent/permission to Open Space Dance's provided Adult chaperone for the duration of the Summer Dance Intensive.

Parent/Guardian Contact Information

Parent/Guardian First name

Parent/Guardian Last name

Relationship to Student

Phone

Child/Student Contact Information

Child/Student Name

Phone

Child/Student Birthday

Month

Day

Year

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Travel Plans

My Child will be traveling

Domestically

Internationally

Travel Plans: EST ARRIVAL DATE + TIME (Check-in / June 28)

Month

Day

Year

Time

HoursMinutes

Travel Plans: EST DEPARTURE DATE + TIME (Check-out / July 18 / 10AM)

Month

Day

Year

Time

HoursMinutes

Consent/Permissions

I, as the parent/guardian give my/our consent and permission to the Open Space Dance Chaperone, to accompany my child at all times WHILE they are ON PSU Campus. Only exception to this is while child is physically in their individual dorm room. This is accordance with the Portland State University rules and regulations.If you do not allow our Chaperone to accompany your child at PSU, you will be required to accompany them.

I, as the parent/guardian give my/our consent and permission for my Child to travel WITH the Open Space Dance Chaperone OFF Campus. (Traveling to/from Open Space Dance)

OFF CAMPUS Travel + Activity:

Each student will be required to Check-out and Check-in with the chaperone before/after leaving Campus. ONLY if given parent/guardian permission to do so.

Off Campus Travel Times: Between the hours of 5:00pm – 9:00pm, MON-FRI, and 7:00am - 9:00pm, SAT-SUN. 9PM Daily Curfew.

Parent/Guardian Permission WITHOUT Chaperone:

I DO give my Child/Student permission to travel WITHOUT a Chaperone OFF CAMPUS, during off hours.

I DO NOT give my Child/Student permission to travel WITHOUT a Chaperone OFF CAMPUS, during off hours.

Open Ended Tickets // March 19 - 22

CHILD TRAVEL CONSENT FORM

State of Oregon

Parent/Guardian Contact Information

Child/Student Contact Information

Emergency Contact

Travel Plans

Consent/Permissions