LOCAL ACTIVITY CONSENT FORM Appointment of ... - What is CISV?

CISV QC Chapter
Unit 320 Mile Long Building
Corner Amorsolo and Herrera Streets, Makati
Telephone Number: (02) 815 3326
hello@qc.cisv.ph
LOCAL ACTIVITY CONSENT FORM
Appointment of Temporary Guardian, Medical Care, Release and Consents
This form is to be completed by the parent or legal guardian and must be duly notarized.
The signed and notarized original must be submitted prior to the program to the Camp Director, who, in turn, must
carry the same during the entire duration of the CISV Mini Camp program.
Signing and submitting this form is a precondition for participation in the CISV Mini Camp Program.
Name of Participant:
Last Name, Given Name/ Suffix, Middle Name
A. Travel.
I give permission for my child to travel to and from the site of the CISV program with the CISV Adult Leader and/or
Program Staff.
B. Appointment of Leader and/or Program Staff as Temporary Guardian.
I appoint the Adult Leader and/or Program Staff as the temporary guardian of the participant for the purpose of
consenting to medical treatment if prompt medical attention is needed and providing the prescribed medication. If
the Adult Leader/ Program Staff is not available, I also appoint CISV personnel from the local Chapter to consent to
medical treatment on behalf of the participant.
C. Acceptance of Online Forms
I confirm that I personally accomplished and submitted my child’s information through and online form. I
understand the notes and questions in the form and I declare that the information I gave about myself, my family
and my child is true and complete. I understand that CISV will rely on the medical information I have provided
about my child and that if I make any false statements, or provide any false and misleading information, I cannot
hold CISV or any of its members liable for relying on the information I so provided. I certify that I have read all the
contents of the online form, particularly the pick up and drop off points and I undertake to appear thereof on time.
I also authorize CISV to accept the online form in place of a signed copy thereof provided that the Local Activity
Consent Form is completed, notarized and submitted to Camp Staff on the day the Camp is to begin.
D. Medical Insurance and Financial Responsibility for Medical Treatment.
Should there be a need for medical attention, the medical health card or medical insurance of the participant shall
cover the related medical expenses. If the medical health card or medical insurance is not accepted, I accept full
financial responsibility for the necessary medical expenses of the participant.

E. Legal Release and Responsibility to Pay for Damage.
I understand the nature of the CISV program and I consider my child capable of taking part in it.
I agree not to take any claim or file a lawsuit against CISV if my child is injured while traveling to/ from and
participating in the CISV program, 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 rules
and rules and regulations of CISV.
F. If my child is engaged in inappropriate behavior he/ she may be sent home before the end of the
program at CISV’s discretion. I also agree to pay for any damage or injury caused by my child.
G. Membership
I understand that as part of the participation in the CISV program, CISV may keep records of my child’s name and
contact details and may use this information for internal administration of membership and participation and may
contact my child in the future with information about the organization.
H. Permission to Use of Images and Art or Written Work.
I agree that CISV may use and publish photographs, artwork and written work as well as audio and video created
as part of participation in the CISV program. CISV may use these items in the production of educational or
promotional materials including web pages.
In consideration of the mutual opportunities offered by CISV, we pledge our cooperation and support to the
organization and all its activities.
We waive any and all rights, claims or damages of any nature whatsoever which we may have against CISV
Philippines and/ or its Local Chapters arising out of unforeseen and fortuitous events while the CISV program is in
progress.
______________________________
Signature of Parent/ Legal Guardian
Over Printed Name
____________________________
Date
______________________________
Signature of Witness
Over Printed Name
____________________________
Date

A C K N O W L E D G E M E N T
REPUBLIC OF THE PHILIPPINES )
City of ____________________)SS.
X ---------------------------------------X
BEFORE ME, a Notary Public for and in the City of ________________________________________, Philippines this
________________________________________ personally appeared _________________________ with his/ her
Community Tax Certificate No. ________________________________ issued at ____________________________
on _______________________ known to me and to me known to be the same person who executed the foregoing
instrument and he/ she acknowledged to me that the same is his/ her own free and voluntary act and deed.
Doc. No. __________;
Page No. __________;
Book No. __________;
Series of __________.