18歳未満 WRITTEN CONSENT FOR CHILD UNDER …

1 18 WRITTEN CONSENT FOR CHILD UNDER 18 YEARSTRAVELING WITH ONLY ONE PARENT OR WITHOUT EITHER PARENT TO WHOM IT MAY CONCERN:I(WE) AUTHORIZE THE MINOR Name: 18 .Passport No: .Travel to: ___ ___ From: / / To: / / .Purpose of His / Her Trip is:__ Sightseeing School excursion Short-term study abroad ACCOMPANIED BY THE FOLLOWING PERSON(S) Name: .Relation: Leader Tour conductor Passport No: .Address: 1-1 Chiyoda, Chiyoda-ku, Tokyo, Japan Date of birth: / / TEL: UNDER THE RESPONSIBILITY OF _____Accompanied parent s Passport No.

2 REFERENCE (ex : HOTEL) Name: _____( Relation Hotel / Others: __ ) Address: _____TEL: _____ 1 1 Father (Print Name):__ Taro Yamada Signature: .Contactinformation Phone number,etc. : .Date: / / .Mother(Print Name ): HanakoYamada)Signature: .Contact information Phone number,etc. : .Date: / /.