Youth Legal Information Form - Appointment of Temporary Guardian for Travel and Medical Care, Release and Consents (YLIF)
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 international programme. 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 CISV Programme (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 Country Code Area Code Telephone Mobile Number Fax Number E mail Alternate Emergency contact phone number

Local 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 the