Pre-Camp 1 - CISV Denver - CISV USA

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Pre-Camp 1 - CISV Denver - CISV USA Powered By Docstoc
					2011 WRMC presents
   Pre-Camp 1
                                Registration Information
Please e-mail the registration form to Gina Beasley at gjbeaz@yahoo.com

Then mail the following, postmarked no later than August 17, 2011: (Any forms mailed later
will incur a late fee of $20 per participant).

 1. Registration Fee – $130 per person. Checks payable to CISV RMD.
    Participants must be 11+ years of age.
    *Chaperones are not charged a registration fee.

 2. WRMC 2011 T-Shirts – There will be a WRMC t-shirt available for
 preorder. Put t-shirt size on registration form and send in an additional
 $10 per shirt - checks payable to CISV RMD.

 3. Registration Form (see end of pre-camp)

 4. Forms – The following forms need to be returned:
 Ages 11-17 traveling with a chaperone: Registration Form, YLIF (Domestic), JB Code of
 Conduct, Health Form, Parental Release Form (for all participants under 18), and
 Participant Release Form (for participants over 16)
 Ages 11 -17 traveling without a chaperone: Registration Form, TWAL, JB Code of
 Conduct, Health Form Parental Release Form (for all participants under 18), Participant
 Release Form (for participants over 16)
 Ages 18+: Registration Form, ALIF, JB Code of Conduct, Health Form, Participant Release
 Form
 Note: Forms DO NOT have to be notarized.
        Health Form 2000 need only be filled out and signed by the parent or guardian
        You may also use your Health Form from this summer if you traveled.
        The Registration Form, JB Code of Conduct, YLIF (domestic), Health
        Form 2000, Parental Release Form and Participant Release Form are attached. Please
        visit http://resources.cisv.org for the TWAL, or ALIF Release Forms.

 Mail to:
 Gina Beasley
 10155 White Oak Way
 Highlands Ranch, CO 80129
 gjbeaz@yahoo.com
 303-921-2328

 We are pleased to have space for 100 participants but registration will be taken on a first come,
 first serve basis and we hope to fill every spot.
Secondary Information
Chaperones: Each chapter must send one chaperone per 8 participants.

Campsite Address:
JeffCo Outdoor Lab School
201 Evans Ranch Road
Evergreen, CO 80439


Arrival in Denver: Friday, September 2 nd , 2011 between 4 p.m. to 8 p.m.
Transportation will be provided from the Denver International Airport, the
                 airport code is DEN. (We strongly urge you to arrive by 6:00pm
                 in order to not miss out on the introductory activities.) The site is
                 at least an hour from DIA, so please take that into consideration
                 when booking your flights. Also, please make sure you have the
                 directors’ and planner’s phone numbers on hand when you arrive in
case there is a problem.
Departure from Denver: Monday, September 5 th, 2011 after 2:00 pm.

** You must schedule flights to fall within these time slots!

Denver has a semi-arid climate with four distinct seasons. Denver’s weather is heavily
influenced by the proximity of the Rocky Mountains to the west. Summer in Denver
you can expect very warm days with low humidity and cool evening breezes. During
the summer months, Denver can have frequent short (and occasionally severe) late-
afternoon thunderstorms.

 Because of our climate, high altitude, and less oxygen than most of the cities you
  will be travelling from, it is extremely important to remain hydrated by drinking
  plenty of water on the plane and throughout your time here in Denver. Also,
  plenty of sunscreen to prevent sunburns!!
Packing List:
Sleeping bag and pillow!!!!
Clothing (Shorts/pants/shirts/etc.)
Warm jacket (We will be in the mountains. It can get chilly at
night)
Tennis Shoes for running games
Flip Flops
Towel and Washcloth
Toiletries – soap, shampoo, etc
Water Bottle!!! (Let’s be eco-friendly and not have to waste cups!)
Flashlight
Bug Spray
Sunscreen
CISV Spirit


Food/Money:
Meals will be provided Friday Night, all day Saturday and
Sunday, and Monday Breakfast. Participants flying in for
WRMC need money for lunch at the airport before flying
home on Monday.

The CISV Denver Store will be open at the very end of camp
for anyone who wishes to purchase CISV items. Cash and checks
ONLY.

YOU MUST TELL US PRIOR TO ARRIVAL IF YOU HAVE ANY DIETARY
NEEDS OTHERWISE WE WILL NOT BE ABLE TO ACCOMMODATE YOU.
Health/Emergencies:
Health Form MUST be filled out but does not require a doctor’s signature.
You may also use your forms from this summer if you traveled. Please
make sure you note any health concerns or allergies on the form that we
will need to know. If you left off anything, feel free to get in touch with
the staff.

Katherine Moyle (Co-Director):
katemoyle@gmail.com
303-956-9237


Jonah Berger (Co-Director):
bluewoodfire@hotmail.com
(303) 827-4218

Corrie Houck (Planner):
Corrie.houck@gmail.com
303-918-5646


Gina Beasley (Registrations):
gjbeaz@yahoo.com
303-921-2328
 Registration Form

Please fill out one form per WRMC participant. This information is necessary for the staff to make the
best accommodations. Thank you.

 Chapter
 Participant Name
 Chaperone Name(s)
 Age
 T-Shirt Size?

ARRIVAL - The above participant will arrive at:

AIR       Name or          Name of Airline Date of arrival            Local time      Where is the
          Code of          and flight      (day / month /             of arrival      plane coming
          Airport          number          year)                                      from?


*If driving, please let us know estimated time of arrival/departure

DEPARTURE - The above participant will leave from:

AIR       Name or          Name of Airline Date of                    Local time      Where is the
          Code of          and flight      departure                  of              plane going?
          Airport          number          (day / month /             departure
                                           year)


SECODARY CONTACT - Name and address of the person whom the staff should contact if any
questions arise regarding travel arrangements. This can be a family member or a CISV Official from our
host chapter. If you would like to give an additional contact, please just copy and paste this address
box and fill in the relevant information.

Given Name and Surname
Position in the NA/Chapter
Number & Street
Town/City and
State/Province
Country                                                   Postcode / Zip Code
                                   Country Code         Area Code           Local Number
Telephone
Fax
Mobile Number
E mail

MAIL FORMS WITH A CHECK PAYABLE TO CISV RMD FOR $130 ($140 with a t-shirt) PER PARTICIPANT
TO:    Gina Beasley
       10155 White Oak Way
       Highlands Ranch, CO 80129
       gjbeaz@yahoo.com
       303-921-2328
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 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 _______


Part 10: Use of the CISV Friends Website
I give my child permission to register on the CISV Friends website. CISV Friends is designed to assist CISV with its
administration of the CISV Activity and to help CISV participants to stay in touch with each other after the CISV Activity.
Part 11: National Code of Conduct for Junior Branch USA
Please  each box after reading each statement,
 I acknowledge that I have read, am familiar with, understand, and agree to respect and abide by Info File R-7 (0432)
         standards, guidelines, and recommendations.
 I will abide by all local laws, including those regarding the buying and consuming of alcohol and tobacco products, and
         standards of acceptable public behavior. I will not consume or purchase tobacco products if under the age of 18 and
         under no circumstances will I purchase or consume alcohol if under the age of 21. In addition, if I am of age, I will
         not purchase or provide these items for someone else. The possession and consumption of illegal drugs will not be
         tolerated under any circumstances.
 Only people who are assigned to my room/cabin/house will sleep there. In addition, I will respect and follow any
         additional rules set for the given activity in relation to visitors being in my room.
 I will abide by the curfew set for nighttime activities (if applicable). This means I will be in my room/cabin/house before
         the established time with no questions asked.
 I will exhibit respectful and reasonably quiet behavior in all areas of the site including bedrooms, hallways, elevators,
         public areas, and meeting rooms. In addition, I will show respect towards all hotel/site employees and CISV
         chaperones.
 If I wish to leave the site for any reason, I understand that I must go with and/or get the permission of my chaperone. I
         understand that it is important that my chaperone must know where I am at all times. I also understand that if I drive
         somewhere, I will only drive with someone who is over 25 years old as per CISV USA’s insurance policy.
 I will be on time to, attend, and fully participate in all activities throughout the entire program.
 I will abide by any additional rules.
 I understand that if I violate any of the items on this agreement I will be subject to disciplinary action decided upon by
         the staff of the activity, including but not limited to having my participation limited in future activities to being sent
         home at my own expense. I also understand that I will have to pay for any damage to the site that I cause.

Part 12: Parent/Guardian Signature
Print ________________________________________




        Participant Signature and Date                                  Parent Signature and Date
 Completed forms are not to be transmitted by E-mail                                  Page 1 of 2   HF 2000

    CHI L DRE N’S I NT E RNAT I ONA L                                                     S UMME R                        V I L LA G E S
  AN INDEPENDENT, NON - POLITICAL, VOLUNTEER ORGANIZATION PROMOTING PEACE EDUCATION AND CROSS - CULTURAL FRIENDSHIP

CISV Health Form – HF 2000 Please complete in English either by typing or by hand                              in black ink, using capital letters).
Participant’s family name:                                                             Gender: Male  Female 
        first / given names:                                                           Date of Birth:            /         /
                                                                                                          dd         mm           yyyy
Participant will attend CISV activity in (Host Nation):
Total days away from home:
In case of Emergency please contact:
Name:                                                                                     Language spoken:

Telephone (Home):                    /            /                                     Telephone ( Office)                   /          /
              Codes:       Nation        Area         number                                     Codes:              Nation       Area       number

Physician’s Declaration Concerning CISV Participant:
Height (cm)            Weight (kg)                                  Blood Pressure         /      Stomach Palpitation

Heart / Lung Stethoscopy                                            Hernia: Yes  No                     Menstrual Disorder: Yes  No 
This CISV participant has received all recommended vaccinations for travel to the host nation: Yes  No 
Is the general physical condition:                                  Normal  Abnormal 
Is the general emotional / mental condition:                        Normal  Abnormal 
Is vision / hearing:                                                Normal  Abnormal 
Is the nutritional condition:                                Normal  Abnormal 
Is there evidence of alcohol or drug dependence?                  Yes  No 
Is there evidence of infectious disorders and / or sexually transmitted disease: Yes  No 
Details of Abnormal findings and / or other comments (including past infections & chronic / recurring conditions):



Medication: (Prescription or over the counter / self-medication). Please ensure sufficient supply for trip’s duration.
Is participant taking medication? Yes  No  If yes, state condition being treated:

                                                                             Dosage:                                                         Renewable
Brand name                           Generic Chemical Description            Morning       Noon         Evening           Night              Prescription
                                                                                                                                                Yes  No 
                                                                                                                                               Yes  No 
                                                                                                                                               Yes  No 

Medication Instructions (with / before / after meals, at bedtime, etc, and contraindications, not with food / alcohol, etc):


This Participant may take part in all activities with the following Restrictions or Recommendations:                                     None 
Details of limitation on participation (if any):


Signature:                                                          Name (please print)
                       Examining Physician                                                       Examining Physician

Date:         /        /                                           I am  am not  the CISV participant’s “usual” physician.
         dd       mm       yyyy

In case of hospitalization by CISV, participant’s medical records are available from:
Name (please print):                                                                    Telephone:                   /               /
                                    Physician   / Hospital                              Codes:          Nation            Area               Records Office


NB: This information is confidential. It will be destroyed as provided by law. The only official text for this form is this English edition.
CISV Health Form – HF 2000 continued Page 2 of 2.         Completed forms are not to be transmitted by E-mail
Carry this form with the relevant CISV Legal / Insurance Form – TWAL , ALIF or YLIF.
Parent / Adult Participant, please complete in English. For international use, please complete and carry official English language
forms.

Participant’s name:                                                                           Country:

Medical History: Apart from minor childhood illnesses, is the participant’s health generally good? Yes  No 
Yes No         Year        Infection History                   Immunization History:                 Yes No       Year     Booster

                          Measles (Rubeola)                               Measles (Rubeola)                                
                          Mumps                                           Mumps                                            
                          Rubella                                         Rubella                                          
                          Chicken Pox (Varicella)                         Chicken Pox (Varicella)                          
                          Whooping Cough (Pertussis)                      Polio                                            
                          Scarlet Fever (Scarlatina)                      Diphtheria                                       
                          Rheumatic Fever                                 Tetanus Toxoid                                   
                          Otitis (inflammation of the ear)                HNIG (human normal immunoglobulin)               
                          Hepatitis (specify)                             Hepatitis (specify)                              
                          Meningitis                                      Meningitis (specify Hib  or C )                
                          Yellow Fever                                    Yellow Fever                                     
                          Malaria                                         Malaria Prevention (specify)                     
                          Frequent Tonsillitis                            Typhoid                                          
                          Sinusitis                                       Influenza (specify)                              
                          Bronchitis                                      Encephalitis (specify)                           
                          Pneumococcal Infections                         Other (specify)                                  
                          Streptococcal Infections                        Other (specify)                                  
                          Staphylococcal Infections                       Tuberculin (BCG)                                 
                          Tuberculosis (TB)                               Alternative / additional TB test information (if any):
                            Chest X-ray Result                              TB Test (tick  below)                        Test Date         Result
                                                                            Mantoux / PPD  or Heaf / Tine 
Yes No     Year           Hospitalization History
                                                                                                  Details (re past / chronic / recurring conditions)
                        Diseases / injuries requiring X-ray examination (specify):
                        Illnesses requiring hospitalization (specify):
                        Injuries requiring hospitalization (specify):

Yes   No   Chronic Conditions & Recurring Medical Problems
         01. Drug reactions (specify drug & reaction, give details)
         02. Other allergic reactions (food, animal, plant, give details)
         03. Asthma or other lung / respiratory disorder (give details)
         04. Enuresis (bed wetting)
         05. Endocrinal disorder: Diabetes  Thyroid  (give details)
         06. Epilepsy
         07. Gynaecological / Menstrual disorder
         08. Kidney / stomach disorder (give details)
         09. Heart / blood pressure disorder (give details)
         10. Ear / nose / throat disorder (give details)
         11. Frequent Diarrhoea or Dysentery
         12. Sleep disorder
         13. Other disorders (give details)
         14. Emotional / behavioural counselling (give details)
         15. Wears braces or has “caps” / artificial teeth
         16. Glasses / contact lenses (carry copy of prescription)
         17. Physical limitations (give details)
         18. Special diet (give details)
Signature:
Date:      /          /
                          of Participant’s Parent / Adult Delegate / Staff (as relevant)                        dd       mm         yyyy

This information is confidential. It will be destroyed as provided by law. The only official text for this form is this English edition.
 Code of Conduct




                                       National Code of Conduct for Junior Branch USA
                                        (To be signed by participant and parent/guardian)
                                        Please  each box after reading each statement,


I, __________________, of __________________ (chapter), understand that by checking these boxes, I agree to and will abide by this code
of conduct for ___________________ (activity name) to be held from __/___/___ to __/__/__.

        I acknowledge that I have read, am familiar with, understand, and agree to respect and abide by Info File R-7 (0432) standards,
         guidelines, and recommendations. (attached)

        I will abide by all local laws, including those regarding the buying and consuming of alcohol and tobacco products, and standards of
         acceptable public behavior. I will not consume or purchase tobacco products if under the age of 18 and under no circumstances will
         I purchase or consume alcohol if under the age of 21. In addition, if I am of age, I will not purchase or provide these items for
         someone else. The possession and consumption of illegal drugs will not be tolerated under any circumstances.

        Only people who are assigned to my room/cabin/house will sleep there. In addition, I will respect and follow any additional rules set
         for the given activity in relation to visitors being in my room.

        I will abide by the curfew set for night time activities (if applicable). This means I will be in my room/cabin/house before the
         established time with no questions asked.

        I will exhibit respectful and reasonably quiet behavior in all areas of the site including bedrooms, hallways, elevators, public areas,
         and meeting rooms. In addition, I will show respect towards all hotel/site employees and CISV chaperones.

        If I wish to leave the site for any reason, I understand that I must go with and/or get the permission of my chaperone. I understand
         that it is important that my chaperone must know where I am at all times. I also understand that if I drive somewhere, I will only drive
         with someone who is over 25 years old as per CISV USA’s insurance policy.

        I will be on time to, attend, and fully participate in all activities throughout the entire program.

        I will abide by any additional rules.

        I understand that if I violate any of the items on this agreement I will be subject to disciplinary action decided upon by the staff of the
         activity, including but not limited to having my participation limited in future activities to being sent home at my own expense. I also
         understand that I will have to pay for any damage to the site that I cause.




             Participant Signature and Date                                               Parent Signature and Date




                                                                                          Parent Print Name and Preferred
                                                                                                  Contact Number




                                                                Activity
 INFO FILE R-7 (0432)
This replaces R-7 (9940)

BEHAVIOUR AND CULTURAL SENSITIVITY

Appropriate behaviour is expected by and within CISV, at every level of the organization, in order to realize:
   CISV’s objects as outlined in the Memorandum & Articles of Incorporation and Constitutional Rules of CISV International Ltd;
   CISV’s educational goals and methods as approved by the Board of Trustees; and
   the personal expectations of participants and volunteers.

For most people appropriate behaviour is inherent within the concepts of common sense, good manners, or being a good host / guest
/ friend. Given the great cultural diversity within CISV, the Board finds it helpful to stress certain qualities in CISV participants’
behaviour -- especially in adults and juniors acting as “role models” for youth in an international educational programme stressing
peace and cross-cultural friendship. Equally, participants who are guests of the host CISV Chapter, family or resident site are
expected to conform to agreed upon concepts of behaviour. No list of norms can anticipate every situation; there is no substitute for
proper selection (or de-selection prior to participation, if necessary), and appropriate training / orientation.

Behaviour expected of all adults and youth in CISV programmes / administration falls within three categories:
(1) Standards; (2) Guidelines: and, (3) Recommendations. Sanctions & procedures are set by Board policy.

STANDARDS relate to a class / type of FORBIDDEN behaviour, violation or reasonable suspicion of which may invoke the most
severe sanctions (including notification, exclusion, early return home or loss of membership).

Forbidden behaviour includes:
   intimacy / sexual relations between children or youth and ANY adult or older youth acting in a position of trust or as a role model
    within CISV (whether locally legal or not);
   use of narcotic / hallucinogenic drugs or chemicals (whether locally legal or not);
   criminal / illegal acts or failure to take action if legally required;
   use of or access to firearms / ammunition or other weapons (within host family home or at CISV site); and
   xenophobic behaviour, discrimination, intolerance or lack of cultural flexibility / openness.
   physical / psychological abuse and corporal punishment.

GUIDELINES relate to a class / type of UNACCEPTABLE behaviour, violation or reasonable suspicion of which may invoke serious
sanctions (including notification, temporary exclusion or loss of membership).

Unacceptable behaviour includes:
   abuse of alcohol -- especially in situations where youth are present in an educational context;
   nudity within CISV programmes or activities (games, swimming etc) or within CISV’s community               living     arrangements
    (Villages, camps or family stay) which violate concepts of privacy or modesty,         whether defined by the cultural norms of the
    host or guest;
   sexual intimacy -- or the appearance of sexual intimacy in programme activities or between consenting adults, while “off duty” or
    between youth participants while taking part in an official CISV program or activity;
   violation of public health standards which jeopardize the health or safety of the participant or others; and,

RECOMMENDATIONS relate to a class / type of INAPPROPRIATE behaviour, violation of which may invoke a less serious sanction /
reprimand (including notification, restricted participation or ban on being officer / staff).

Inappropriate behaviour includes:
   failure to respect / provide reasonable dietary, health, security and comfort requirements for participants (e.g. vegetarians,
    asthmatics, non-smokers, bathing privacy, adequate sleep, emergency communication);
   failure to respect the privacy of participants, host family members or site staff (including their personal luggage or effects), except
    in cases of suspected illegal activity, violation of CISV standards / guidelines, or medical confidences when the participant’s
    behaviour is a threat to the health / safety of the participant or others (NB: standards of confidentiality regarding patient’s medical
    information / treatment vary widely);
   failure to respect “house rules” of host families or sites hosting the CISV programme / activity (including insensitivity in observing
    known “local” customs or courtesies);
   failure to respect differing personal and cultural standards of appropriate educational activities & discipline or sanctions; and,
   failure to use appropriate methods to resolve personal / group conflict in intercultural living / activities.

Respect for appropriate behaviour is considered so universally important within CISV that the content of this document must be
observed and incorporated into CISV’s programmes, activities and administration at every level of the organization. CISV National
and Promotional Associations may supplement these declarations, but they may not contradict the wording or effect of official CISV
International policy.
                       Children’s International Summer Villages, Inc.
                                   Parental Release Form

       UNCONDITIONAL RELEASE OF LIABILITY & AGREEMENT TO INDEMNIFY
                                                  (the “Agreement”)

               ***THIS IS A LEGALLY BINDING AGREEMENT. PLEASE READ CAREFULLY***

Youth Participant:       _________________________________________ Date of Birth: __________
                         First       Middle              Last

Parent or Guardian:      _________________________________________
                         First        Middle             Last

CISV Program:            ___________________________ Chapter: ______________________

I. PARTIES BOUND BY THIS AGREEMENT
          A. CISV: As used in this agreement, the term CISV includes Children’s International Summer Villages,
Inc., an Ohio not-for-profit corporation, including its Chapters and Steering Committees, (CISV-USA), and CISV
International, Ltd, (CISV International) including all National Associations and Promotional Associations, together
with all leaders, staff, volunteers, employees, agents, officers, directors, shareholders.
          B. CHILD/PARTICIPANT: As used in this agreement, the term Child or Participant includes the
individual participating in the CISV program stated above, the participant’s parents, guardians, and heirs.

II. UNCONDITIONAL RELEASE OF LIABILITY

          In consideration for my child, _____________________________, being permitted to participate in the
CISV program described above, I, ______________________________, hereby release CISV from any and all
claims and liability of any kind that may arise as a result of my child’s participation, including but not limited to
claims regarding or alleging CISV’s negligence. This release includes all travel to and from the program and
activities in preparation for participation in the program described above. By signing this agreement, the
Participant releases CISV of any and all liability, waives any and all claims against CISV, and agrees not to sue
CISV based on from the participant’s involvement in the program stated above.

III. AGREEMENT TO INDEMNIFY

         As further consideration of my child’s participation in the CISV program described above, I agree to hold
harmless and indemnify CISV for any and all claims that may be brought against CISV as a result of my child’s
participation in the program stated above, including all costs and attorney fees incurred, as well any other
expenses.

IV. SEVERABILITY

         In the event that any term of this agreement is found to be invalid for any reason, such a finding shall not
affect the validity of any other terms of this Agreement.

VI. PARENTS/GUARDIAN(S) CONSENT AND ACKNOWLEDGMENT
       I have read and fully understand the terms of this Agreement. I UNDERSTAND THAT I HAVE GIVEN
UP SUBSTANTIAL RIGHT BY SIGNING THIS DOCUMENT.

SIGNATURE: ________________________________ Date: ________________
                       Children’s International Summer Villages, Inc.
                                 Participant Release Form

       UNCONDITIONAL RELEASE OF LIABILITY & AGREEMENT TO INDEMNIFY
                                                  (the “Agreement”)

               ***THIS IS A LEGALLY BINDING AGREEMENT. PLEASE READ CAREFULLY***

Participant:     _________________________________________ Date of Birth: __________
                       First        Middle             Last


CISV Program:            ___________________________ Chapter: ______________________

I. PARTIES BOUND BY THIS AGREEMENT
          A. CISV: As used in this agreement, the term CISV includes Children’s International Summer Villages,
Inc., an Ohio not-for-profit corporation, including its Chapters and Steering Committees, (CISV-USA), and CISV
International, Ltd, (CISV International) including all National Associations and Promotional Associations, together
with all leaders, staff, volunteers, employees, agents, officers, directors, shareholders.
          B. PARTICIPANT: As used in this agreement, the term Participant includes the
individual participating in the CISV program stated above, and heirs.

II. UNCONDITIONAL RELEASE OF LIABILITY

         In consideration for my being permitted to participate in the CISV program described above, I,
______________________________, hereby release CISV from any and all claims and liability of any kind that
may arise as a result of my child’s participation, including but not limited to claims regarding or alleging CISV’s
negligence. This release includes all travel to and from the program and activities in preparation for participation
in the program described above. By signing this agreement, the Participant releases CISV of any and all liability,
waives any and all claims against CISV, and agrees not to sue CISV based on from the participant’s involvement in
the program stated above.

III. AGREEMENT TO INDEMNIFY

         As further consideration of my participation in the CISV program described above, I agree to hold
harmless and indemnify CISV for any and all claims that may be brought against CISV as a result of my
participation in the program stated above, including all costs and attorney fees incurred, as well any other
expenses.

IV. SEVERABILITY

         In the event that any term of this agreement is found to be invalid for any reason, such a finding shall not
affect the validity of any other terms of this Agreement.

VI. PARTICIPANT’S CONSENT AND ACKNOWLEDGMENT
       I have read and fully understand the terms of this Agreement. I UNDERSTAND THAT I HAVE GIVEN
UP SUBSTANTIAL RIGHT BY SIGNING THIS DOCUMENT.

SIGNATURE: ________________________________ Date: ________________
RELEASE FORM: NOTE OF EXPLANATION
        For over fifty years, Children’s International Summer Villages (CISV) has worked to
increase cross cultural understanding among the children of the world. Over 150,000 young
people have been transformed by personal experience through CISV’s multi-cultural
educational program. Since the first Village in 1951, CISV volunteers have worked to provide
healthy and secure opportunities for our participants to learn about the world and themselves.
We are proud of our results and work hard to earn the trust of parents who allow their children
to participate in CISV.

       Although the health and safety of all CISV participants is of great importance to the
worldwide network of volunteers that make the CISV program possible, in recent years, the
cost of property and liability insurance has increased steadily despite our risk management
program.

        In order to ensure the continued operation of the CISV program, the Board of Trustees
of CISV, Inc. (CISV-USA), voted to require a liability release as a condition of participation
effective with our 2005 programs. For this reason, in order to participate as a CISV delegate, a
parent or legal guardian of all youth participants under the age of 18, must execute an
UNCONDITIONAL RELEASE OF LIABILITY & AGREEMENT TO INDEMNIFY. (Parental
Release Form) All participants age 16 or older, including all leaders and staff, also must
personally execute an UNCONDITIONAL RELEASE OF LIABILITY & AGREEMENT TO
INDEMNIFY. (Participant Release Form).

        Although CISV will work to maintain liability insurance for the benefit of non-participants,
including schools and other institutions that provide facilities for our programs, we believe that
this release, together with our on-going risk management efforts, will limit the impact of rising
insurance premiums on our ability to offer the CISV program in the United States.

      CISV USA continues to ask all participants to carry their own medical insurance.
Medical insurance provided by CISV USA is intended as secondary insurance and is part of
CISV efforts to meet standards established by the Council on Standards for International
Educational Travel.

       Specific questions about CISV’s UNCONDITIONAL RELEASE OF LIABILITY &
AGREEMENT TO INDEMNIFY, and insurance coverage or requirements, should be made, in
writing, to the CISV National Office, 1375 Kemper Meadow Drive, Suite 9-H; Cincinnati, OH
45221.

				
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