PARENTAL DISCHARGE FOR UNDERAGE STUDENTS

(LESS THAN 18 YEARS OLD)

RESPONSIBILITY & MEDICAL EMERGENCY
The following form is mandatory and must be signed and returned to the school France Langue no later than two weeks before classes
begin.

Imhof
SURNAME: …………………………………… Nicole
First name: ………………………………………………………....

14.08.1973
Date of birth: …………………………………

Dates of stay: from 9.

…… / 7.
…… /2023 5./ ……
…… to …… 8. /2023
……

Dear Parents,

Our objective is for your child to easily integrate into his host family and live his stay in the best conditions possible. We kindly
ask you to complete and sign this form and to send it to the school France Langue no later than 2 weeks before the start of
the course. It will be sent to your child's French host family. This completed form will allow the host family to understand and
follow the education your child received. We thank you for your cooperation.

The following rules apply to minor students.

Accommodation
Sarina Imhof
During his stay, my son/my daughter (first name & surname) ………………………….……………….……………. remains
under my responsibility.

If your child is 15 to 17 years old:

He / she is allowed out until 11pm from Sunday to Thursday and until 01:00 am on Friday, Saturday and the eve
of public holidays.

If your child is less than 15 years old:

He / she is not allowed to go out at night.

I understand that students who do not comply with the above rules will receive a warning. Consequently, if students continue
to violate the school rules then they will be dismissed from the programme and sent home at their parents’ expenses and will
not be entitled to a refund.

Emergency
I, the undersigned ……………………………………………………………………………………………………. Authorizes
the direction of the school France Langue or the host family to take the necessary measures in case of illness or accident and
gives them the authorization to have them practice, if necessary, Medical diagnosis, X-rays, treatment, hospitalization, surgery
under local or general anesthesia under the authority of a qualified doctor or specialist, or a repatriation at the expense of
the child's family. We relieve the school of any responsibility for such actions. The student must inform the school of any
serious medical problem before the beginning of the program.

France Langue - Head office: 40 boulevard de la République - 78000 Versailles - SARL with a capital of 15 000 € - RCS Versailles 391 576 592 - VAT number: FR
In case of an emergency I can be reached at (please state clearly):
Tel: ………………………………………………………………………………………………………………………………
Email: ……………………………………………………………………………………………………………………………
Alternatively, please contact: ……………………………………………………………………………………………………
Tel: ………………………………………………………………………………………………………………………………
Email: ……………………………………………………………………………………………………………………………

Responsibility for minors

The responsibility of the school France Langue (hereafter referred to as the school) does not cover all the activities of the
minor student, but only those performed during the time when he is overlooked by the school, in accordance with the
provisions of Article 1242 Civil Code.

In case of absence of the minor student from the course or the extracurricular activities, the school will be exonerated from
any responsibility that could be put in play due to the behavior of the minor student.
Outside the school and the extracurricular activities organized by the school, the minor student remains under the sole
responsibility of his parents.

The responsibility of the host family cannot be sought because of the minor student during the period in which he is entrusted
to him.

During the excursions authorized by the parents and organized by our external provider, and during the time spent in the
host family, the minor student remains under the entire responsibility of his parents.

Indeed, the host family does not have to take part in the education or the supervision of the minor student, but only to host
him, feed him and make sure his stay is as smooth as possible. No delegation of parental authority is established for the benefit
of the host family and the temporary removal of the minor student from the family home is insufficient to destroy cohabitation
in the legal sense.
The parents are solely responsible for their child and his/her behavior outside the time during which he/she is taken care of by
the school, in accordance with the provisions of article 1242 al 4 of the Civil Code.

France Langue - Head office: 40 boulevard de la République - 78000 Versailles - SARL with a capital of 15 000 € - RCS Versailles 391 576 592 - VAT number: FR
 HEALTH FORM

VACCINATIONS (refer to student’s health records or vaccination certificates):

Compulsory vaccines Yes No Dates of last reminders Recommended vaccines Dates

Diphtheria Hepatitis B
Tetanus Rubella-Mumps-Measles
Poliomyelitis Whooping cough
or DT polio Other (details)
or Tetracoq BCG

If the student does not have the compulsory vaccinations, attach a medical contraindication (exemption) certificate. NB:
the tetanus vaccine presents no contraindications

CURRENT TREATMENT:

Will the student be taking medication during his /her stay?  Yes  No

If the minor student will be taking medication, please attach the prescription and the medicine in its original box / packaging
with the student’s name and the instructions). No medication can be given without a prescription.

MEDICAL ISSUES:

HAS THE MINOR STUDENT ALREADY HAD?

RUBELLA  Yes  No
CHICKEN POX  Yes  No
ANGINA  Yes  No
ACUTE RHEUMATOID ARTHRITIS  Yes  No
SCARLET FEVER  Yes  No
WHOOPING COUGH  Yes  No
EARACHE  Yes  No
MEASLES  Yes  No
MUMPS  Yes  No

ALLERGIES:

ASTHMA  Yes  No
MEDICINAL ALLERGIES  Yes  No
FOOD ALLERGIES  Yes  No
OTHERS  Yes  No

France Langue - Head office: 40 boulevard de la République - 78000 Versailles - SARL with a capital of 15 000 € - RCS Versailles 391 576 592 - VAT number: FR
Specify the cause of the allergy and what to do (Specify if self-medication if required)

……………………………………………………………………………………………………………………………………

STATE BELOW: HEALTH ISSUES (ILLNESS, ACCIDENT, CONVULSIONS, HOSPITALISATION, SURGERY, RE-
EDUCATION) WITH DATES AND PRECAUTIONS TO BE TAKEN.
……………………………………………………………………………………………………………………………………
………………………………………………………….…………………………………………………………………………

USEFUL PARENTAL RECOMMENDATIONS

Does the minor student wear contact lenses or glasses, have a hearing aid, dentures, etc.? Details:

……………………………………………………………………………………………………………………………………
………………………………………………………….…………………………………………………………………………

PERSON IN CHARGE OF STUDENT

Contact details of parent or legal guardian to be contacted in the event of an emergency:

SURNAME, First name

……………………………………………………………………………………………………………………………………
Home tel: ………………………… Work tel: ………………………… Mobile tel: ………………………… Email:
………………………………………………….

Name and telephone number of regular doctor (optional):

……………………………………………………………………………………………………………………………………

I, the undersigned, (surname, first name), ……………………………………………………………………., the student’s

parent or legal guardian:
- Confirm that I have read the school Terms & Conditions
- Certify that I have contracted out an insurance for my child’s stay covering civil liability, personal accident, illness
and repatriation, loss and theft of luggage and personal belongings. Insurance company ……………………………,
Insurance contrat n°……………………………
- Declare exact all the information on the health form and authorize the person in charge of the stay to take any
action required in the event of illness of the student: (medical treatment, hospitalisation, surgery).
- Authorise my child to participate in all the excursions organized by the school through an external provider
 Yes  No

Parents’ full name (first name and surname): Signature of the legal guardian:

In: ……………………………… Date: ………………………………

France Langue - Head office: 40 boulevard de la République - 78000 Versailles - SARL with a capital of 15 000 € - RCS Versailles 391 576 592 - VAT number: FR