Cisv International Programme Participant Health Information Form
Download a blank fillable Cisv International Programme Participant Health Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Cisv International Programme Participant Health Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5Health Information Form
CISV International Ltd
Company Registration: 3672838
Telephone: +[44 191] 232 4998
MEA House, Ellison Place
Charity Registration: 1073308
Fax: +[44 191] 261 4710
Newcastle upon Tyne, NE1 8XS
E-mail:
England
GENERAL INSTRUCTIONS:
Thank you for taking the time to complete this form fully. The information it contains will help CISV to plan for your welfare and will
assist any medical practitioners in the event that you should require their care during travel or the programme.
Completing and having this is a condition of participation in CISV international programmes
Please complete this form in English either by typing or by hand, using black ink and in capital letters.
This form must be completed and signed not more than 3 months before participation in the CISV International programme.
You must notify CISV of any relevant changes to the information that may occur prior to the programme.
The information in this form is confidential. It will be destroyed as provided for by law.
The only official text for this form is the English Edition.
Please take the signed original of this form plus any supporting documents and one copy to the programme, and leave one
copy with the sending Chapter.
Parts A, B, C and D are to be filled out by the adult (aged 21+) participant or by the parent/legal guardian of the youth (up to
and including age 20) participant. If the law in your country does not allow parents to know the health information of their
children aged 18+, then the individual should complete and sign these sections and note the age matter in the relevant box
in part D.
Part B – if there are any special needs or allergies, please send the contents of the Part B page to the programme staff in
advance of the programme.
Make sure to take the filled out parts A, B, C and D with you to the doctor (physician), when going for the health check.
Part E is the only part that must be completed by a doctor who meets with and conducts an appropriate health check on the
participant.
Part A: PARTICIPANT INFORMATION
TO THE PARTICIPANT / PARENT / GUARDIAN: Please complete this form and review it with your physician during your
consult.
Participant’s Name:
Last
First/Given
Middle
Gender:
Date of Birth:
Country of Citizenship:
Male
___ ___ ___ ___ ___ ___ ___ ___
Female
dd
mm
yyyy
Participant will attend CISV programme in (Host Nation):
Duration of programme (start date and end date):
Start date:
End date:
In case of emergency, please contact:
Language(s) spoken:
Contact number (Home):
Contact number (Office and/or Mobile):
-
-
-
-
country code
area code
number
country code
area code
number
CISV International Ltd
(Valid from 2015)
Page 1 of 5
Official Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical