Fillable Youth Legal Information Form - Canada (Page 2 of 3) in pdf

CISV Canada Youth Legal Information Form -- Appointment of Temporary Guardian for Travel and Overnight Programmes

(YLIF-CAN)

Part 2: Appointment of Temporary Guardian and Health & Consent for Medical Treatment

I hereby appoint the Adult Leader/Chaperone named above (if applicable) as a Temporary Guardian of the Participant.

I authorize CISV personnel (Leader/Chaperone, Programme Staff or Host Family) to provide consent for medical treatment

on behalf of the Participant if emergency care is required.

FROM

(d/m/yy)

Name of Province & Health Card Number

Health Information

(provide specific information: medication dosage and administration; allergies & severity; etc.)

Dietary Information

(Vegetarian? Celiac? Please include allergies or strict limitations only, not preferences)

Other information that you would like to share with the organizers/leaders/staff in order to ensure a positive experience

Note: All information will be taken into consideration however, due to site or other constraints certain accommodations may not be possible.

Organizers will discuss with Participant.

Part 3: Legal Release & Responsibility to Pay for Damage

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

understand my child will be participating in activities and discussions that may include, but are not limited to topics of

racism, equality, human rights, gender discrimination, and social justice. These activities are facilitated without bias but may

be emotionally intense.

I agree not to make a claim or file a lawsuit against CISV if my child is injured while participating in this CISV Programme,

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. If my child engages in inappropriate behaviour s/he may be sent home before the end of the Programme

at CISV’s discretion.

I agree to collect my child from camp or to have my child sent home, at CISV’s discretion by method

deemed appropriate by CISV, and to be responsible for costs associated with such trip.

I also agree to pay for any damage or injury caused by my child.

Part 4: Health Form

If the programme is more than seven nights in length, I understand I must provide a properly completed CISV

International Health Form (HF). The HF is to be completed by the Parent or Legal Guardian of the Participant; completion by

a physician is not required.

Part 5: Membership

I understand that as part of participation in the above Programme, the Participant is an Individual Activity Member in CISV

Canada. I agree that CISV will keep a record of the Participant’s name and contact details, will use this information for

internal administration of membership and participation and may contact the Participant.

March 2015 (NRM)

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Youth Legal Information Form - Canada Page 2