Appointment Of Temporary Guardian For Travel And Medical Care, Release And Consent (Page 2 of 3) in pdf

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 (Activity Staff or Host Family) from the Host

Chapter/ CISV USA to consent to medical treatment on behalf of the Participant. This Appointment is valid for the

period stated below.

From (date) ______________________ to (date) _____________________________ .

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 Activity and that I

am responsible for any medical expenses incurred on behalf of my child while at the Activity.

Insurance Company Name __________________________________

Insured ________________________________________ Policy Number _________________________________

6: Legal Release & Responsibility to Pay for Damage

I understand the nature of the CISV Activity noted above and I consider my child to be capable of taking part in it. I

agree not to make a claim or file a lawsuit against CISV if my child is injured while traveling to / from and/or

participating in the above Activity, unless there has been gross negligence on the part of CISV.

My child and I understand that CISV participants are expected to conduct themselves in accordance with local laws

and CISV rules, including the Code of Conduct. If my child engages in inappropriate behavior he / she may be sent

home before the end of the Activity at CISV’s discretion. I will cover the costs of this trip. I also agree to pay for any

damage or injury caused by my child.

Part 7: Membership

I understand that as part of participation in the above Activity my child/our family is a Member in a CISV Chapter

or of the national association. I agree that CISV will keep a record of my child’s name and contact details, will use

this information for internal administration of membership and participation and may contact my child in the

future with information about the organization. A family/child may participate in activities without membership

for the purpose of recruitment.

Part 8: Permission to Use Photographs, Art or Written Work

I agree that CISV may use and publish photographs, artwork, and written work as well as video and audiotape

created as part of participation in the CISV Activity. CISV may use these items in the production of educational or

promotional materials including web pages. These items may be used and published with a child’s first name (or

nickname) and/or age. Unless my specific parental consent is obtained, children will not be identified by full name.

Tick One; ______ I agree to use

______ I do not agree to use.

Part 9: Permission to Swim

I give my child permission to participate in swimming and other water activities. My child’s swimming ability is (tick

one) None _____

Some ________ Good Swimmer _______

Appointment Of Temporary Guardian For Travel And Medical Care, Release And Consent Page 2