Appointment Of Temporary Guardian For Travel And Medical Care, Release And Consent printable pdf download

Appointment Of Temporary Guardian For Travel And Medical Care, Release And Consent

Youth Legal Form- USA, - Appointment of Temporary Guardian for Travel and

Medical Care, Release and Consent:

Use: Activities occurring in the United States (mini camps, NBM, NYM, NLT, etc), youth under the age of 18. THIS

FORM IS NOT FOR USE FOR INTERNATIONAL PROGRAMS WHETHER HELD IN THE US OR OUTSIDE THE US.

This form is to be completed by a parent or legal guardian of the participant. The signed original should be given to

the adult chaperone. A copy shall be retained by the sending Chapter. Signing this form is a condition of

participation in the CISV Activity noted below.

Full Name of Participant ________________________________________ Date of Birth _____________________

CISV Activity and Location _______________________________________________ (Ex. NBM, Cincinnati)

Name of Adult Chaperone ______________________________________________

Adult Chaperone Telephone: Mobile (

) ______________________________

Name and Mobile phone for chaperone in transit if different from chaperone on site (one chaperone while

travelling to site, one at the site):

_____________________________________________________________________

IF APPLICABLE, please check: ______ My child is at least 16 years old and has permission to travel to/from this

activity without an adult chaperone.

Full Name of Participant’s Parent or Legal Guardian __________________________________

Emergency Contact Information That CISV Can Use During the Activity

Name ____________________________________________________________

Address _______________________________________________________________________________

Home Telephone (

) _____________________________ and Mobile Phone (

) _____________________

Participant’s Mobile Phone (

) ________________________ and E mail ______________________________

Alternate Emergency Contact __________________________________________

Alternate Emergency Contact Phone Number (

) _________________________

Part 1: Authorization for Participant to Travel With an Adult Leader and Appointment of Temporary Guardian

I give permission for my child to travel to and from the CISV Activity with the Adult Leader named above. I hereby

appoint the Adult Leader named above as a Temporary Guardian of the Participant named above for the purposes

Appointment Of Temporary Guardian For Travel And Medical Care, Release And Consent