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BELGIAN DISTRICTS 1620 - 1630 - 2170 TRAVEL REQUEST 

For group travel (more than 1 student) submit the unsigned project to the district officer before requesting other signatures.
This travel request form is to be submitted by each participant to his Host Club YEO 15 days prior departure.
The final  request should be sent by the Club YEO to the District Officer 8 days prior departure.

DATE (of request)                                                 FAMILY NAME                                                    First Name                               

Host Rotary Club                                                           Your own Mobile Phone Nr:

Reasons (more particularly why this trip is planned during the school period and/or outside the normal Rotary travelling rules  - copy of the invitation must be attached):

 

Name of other participants to the trip and their Host Rotary Club and district (see footnote):

 

Date of Departure:                         Date of Return:                      Destination (Country, City):

Means of travel (Schedule, routing, Flight Nbr,…):

Day by day full addresses in the visited country (with phone number) (see footnote):

 

Full address (name, address, phone number…) of the responsible adult locally present:

 

Any comment (see footnote):

AUTHORIZATION

NAME

SIGNATURE

DATE
Natural Parents:
Father
Mother

 

 

 
We, parents of ................................................................. exempt Belgian Rotary of any responsibility or liability during this trip.
Host Family:
in Belgium

 

 

 
School Advice (if trip is planned during school period):: 

 

 

 
Host ClubYEO/Chairman
Advice: favourable - unfavourable

 

 

 
Sponsor District Chairman
Advice: favourable - unfavourable		      
District Officer
DECISION :     Granted       Refused

 

 

 

Note : If you need more space, add another sheet of paper.