AUTHORIZATION TO LIVE ABROAD

I, (nome do pai ou guardião legal), bearer of Identity Card number

_____________, issued by ____________, on ___________(data), currently living at
(endereço do pai), in the city of (cidade do pai), state of São Paulo, Brazil, and
(nome da mãe ou guardiã legal), bearer of Identity Card number _____________,
issued by __________ on _______(data), currently living at (endereço da mãe), in the
city of (cidade da mãe), state of São Paulo, Brazil, as parents of (nome do estudante
outbound), passport nº _______________, hereby grant full authorization and consent
for our child to travel unaccompanied outside of Brazil and to live in Belgium for one
year, from August 1st, 2014 to July 31st, 2015, as a Rotary Exchange Student, under the
responsibility and care of Rotary International District (número do distrito anfitrião).

Our son/daughter (nome do estudante outbound) will study at school (nome

da escolar no exterior) and will be hosted by (nome do pai anfitrião) and (nome da
mãe anfitriã), currently living at (endereço, cidade, estado, país da família anfitriã).

Cidade dos pais, July 16th 2014

________________reconhecer firma da assinatura______

Nome do Pai
Father

________________reconhecer firma da assinatura______

Nome da Mãe
Mother