PREFACE Visit/Off-Campus Authorization Form

Please complete this form if any person including parent(s), the custodial parent (s) or guardian(s) may visit your child or take your child off campus while PREFACE is in session and/or on departure day. Your son or daughter will NOT be permitted to leave campus with anyone other than the program staff (for program functions) unless authorized in writing.

Student's Email Address

Student's First Name

Student's Last Name

Student's Date of Birth

The following people have our permission to visit and/or take our child off campus, provided 24 hour advance notice is provided. We also certify that each person listed is an adult over the age of 25. Each visitor will be required to show identification.

Name:

Relationship:

Phone and Address

Name:

Relationship:

Phone and Address

Name:

Relationship:

Phone and Address

Please provide information about any custody issues that may affect your child’s stay at PREFACE. Attach any relevant legal documents in addition to providing the name, email, phone number, and address of your legal counsel, if appropriate.

Sign your submission with your electronic signature (e.g., john smith):

Rensselaer Polytechnic Institute (RPI)

PREFACE Visit/Off-Campus Authorization Form