CISV International Ltd MEA House, Ellison Place Newcastle upon Tyne, NE1 8XS England Company Registration: 3672838 Charity Registration: 1073308 Telephone: +[44 191] 232 4998 Fax: +[44 191] 261 4710 E-mail: International@cisv.org www.cisv.org
Youth Legal Information Form -Appointment of Temporary Guardian for Travel and Medical Care, Release and Consents (YLIF)
This form relates to youth participants (under the age of 16 at the time of departure for the CISV programme) and is to be completed by a parent or legal guardian of the participant. The signed original plus two copies should be given to the Adult Leader, who must carry them to the CISV internationalprogramme. A copy should also be left with the participant’s home CISV Chapter. Note. In this form, unless otherwise specified, “CISV” includes CISV International Ltd, all National and Promotional Associations, together with all leaders, staff, volunteers, employees, agents, members. Signing this form is a condition of participation in the CISV Programme noted below. Full Name of Participant CISVProgramme (e.g. Village 2004-36) Full Name of Adult Leader Full Name of Participant’s Parent or Legal Guardian Participant’s Date of Birth (day / month / year) Host National Association (Country) Leader’s Date of Birth (day / month / year)
Emergency Contact information that CISV can use during the Programme Name Number & Street Town / City Area / State / Province Country Postcode / Zip code CountryCode Area Code Telephone Mobile Number Fax Number E mail Alternate Emergency contact phone number
Part 1: Authorization for Participant to travel with an Adult Leader I give permission for my child to travel to and from the CISV Programme with the Adult Leader named above.
Part 2: Appointment of Adult Leader and others as Temporary Guardian of Participant I hereby appoint theAdult Leader named above as a Temporary Guardian of the Participant named above for the purposes of consenting to medical treatment and providing prescribed medication. If the Adult Leader is not available, and prompt medical attention is needed, I also appoint CISV personnel (Programme Staff or Host Family) from the Host Country named above to consent to medical treatment on behalf of theParticipant. This Appointment is valid for the period stated below. From (day/month/year) To (day/month/year)
Part 3: Health Form I understand that I must provide a properly completed CISV Health Form in order for the Participant to attend the CISV Programme named above.
CISV International Ltd Official Form
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Youth Legal Information Form -- Appointment ofTemporary Guardian for Travel and Medical Care, Release and Consents (YLIF)
Part 4: Medical Insurance & Financial Responsibility for Medical Treatment I understand that the Participant must have medical insurance in order to participate in this CISV Programme. Proof of medical insurance must be provided below or attached to this form. If the insurance is not accepted or does not pay, I acceptfinancial responsibility for the necessary medical expenses of the Participant.
Part 5: Proof of Medical Insurance If you have private medical insurance, please tell us the name of the insurance company and attach a copy of your insurance card or other proof of insurance that can be provided to a doctor or hospital. Name of Insurance Company (Please tell us the policy number) If you have nationalmedical insurance or insurance provided by CISV International or your National Association, please tell us which insurance your have and attach a copy of the proof of insurance you have received. Tick one National / Regional Health Insurance Policy (Please specify the country and policy number below) AON medical insurance arranged by your National Association through CISV International AON medical...