Cisv International Programme Participant Health Information Form Page 4
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5 No
In the past 5 years, has the participant ever been a hospital patient for any other condition? Yes
Date
Diagnosis
Details
For Female Participants:
No
Has the participant started menstruating?
Yes
No
If yes, is there any menstrual disorder?
Yes
What medication can be given for menstrual pain/dysmenorrhea?
No
Is the participant pregnant or is there a possibility that she may be pregnant?
Yes
Immunizations:
Please provide information on immunizations received:
Immunization
Date of inoculation or
Immunization
Date of inoculation or
Yes
No
Yes
No
most recent booster
most recent booster
DPT (Diphtheria,
MMR (Measles,
Pertussis, Tetanus)
Mumps, Rubella)
Polio
Hepatitis A
Measles
Hepatitis B
Chickenpox
Influenza
Meningococcal
Pneumococcal
Other, please
Tetanus
specify:
Has the participant received all the necessary immunizations for travel to your host nation?
Yes
No
Please give details below:
Immunization
Yes
No
Date
PART D: CERTIFICATION
I certify that all responses made on this form are true, accurate and complete, and I will notify CISV International of any relevant
changes that may occur prior to or during my international programme. I have included in this form, advised my CISV Chapter, my
delegation Leader and the programme host Staff of any special needs or assistance that I/the participant may have relating to my/the
participant’s physical and mental health. I am aware that if I do not provide complete information, this may cause hardship and
concern to others and may affect my/the participant’s own welfare. I understand that if I do not provide complete information, CISV
may decide to send me/the participant home from the programme at my/the participant’s own expense.
I consent to the release of medical information to CISV International or its agents so that they may provide me with needed assistance.
I further agree that CISV International or its agents may release information to other persons who may need this information to assist
me/the participant or to assist others in the programme. I understand and agree that this form may be released to the host Chapter or
Programme Director for such purposes.
If my parents or guardians have not signed this form, I represent and certify that I am not a minor according to the laws of my country.
Tick if this is the case
Signature of Participant/Adult Leader or Staff: ____________________________________________ Date: __________________
Signature of Parent/Guardian
of Participant/Junior Leader or Staff: ____________________________________________________ Date: _________________
CISV International Ltd
(Valid from 2015)
Page 4 of 5
Official Form
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