Interchange Delegate Application

Virtual Interchange Participant Application

The information provided on this form will be used by the Local Interchange Committee to evaluate applicants and to match youth with an interchange partner. It will also help the partner delegates get to know each other before their visits. Each section should be completed with as many details and descriptive terms as possible, to help the committee evaluate the applicant and make the best possible match for the delegate.
Youth Applicant Information
Full Name*

First NameLast Name
Date of Birth of Youth Applicant*

MonthDayYear
Gender Identity

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Youth Phone Number

Area CodePhone Number
Youth E-mail
Grade in School
Name of School
Does the youth applicant speak a language other than English. If so, describe fluency level.
What are your (the youth applicant's) interests and hobbies?
What are your (the youth applicant's) activities outside school?
How did you learn about CISV?
What is your CISV background?
Upload a photo of the youth applicant

Browse Files

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Parent/Guardian Information
Name of Parent/Guardian #1 (Parent #1 is CISV's primary contact for your child)*

First NameLast Name
Parent/Guardian #1 Phone Number*

Area CodePhone Number
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #1 Occupation
Parent #1 Employer
Parent/Guardian #1 Office Number

Area CodePhone Number
Address of Parent/Guardian #1 (if different from youth applicant)

Street Address

Street Address Line 2

CityState

Zip Code
Name of Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 Phone Number

Area CodePhone Number
Parent/Guardian #2 Email
example@example.com
Occupation of Parent/Guardian #2
Parent #2/Guardian Employer
Parent/Guardian #2 Address (if different from youth applicant address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CISV requires that both custodial parents/guardians sign this application form (see last page for signature lines), thus confirming that the applicant has permission from both custodial parents/guardians to participate in the virtual interchange. If an applicant is selected, all additional required CISV forms can be signed by just one custodial parent/guardian, unless CISV is informed in advance of custody issues that make necessary the signatures of both.
Check the option that best describes your situation:

Parents/guardians are married.Parents/guardians are divorced and share legal custody.Parents/guardians are divorced and one has full legal custody.Parents/guardians are not married but share legal custody.Parents/guardians are not married and one has full legal custody.Non-parent legal guardian has full legal custody.
If one parent/guardian has custody, name of that person:
Parent/Guardian #1 Response: why do you want your child to participate in a CISV Interchange?
Parent/Guardian #2 Response: why do you want your child to participate in a CISV Interchange?
What are Parent's/Guardian's current volunteer activities?
Parent/Guardian #1 Response: Please describe Parent/Guardian #1 response's volunteer activities?
Parent/Guardian #2 Response: Please describe Parent/Guardian #2's volunteer activities?
Will you be able and willing to volunteer with CISV if your child is selected?
Parent/Guardian #1 answer about willingness to volunteer?
Parent/Guardian #2 answer about willingness to volunteer?
If your child has previously participated in a CISV program, please describe how you have volunteered and supported the chapter in the past 18 months.
Do either or both parents/guardians speak another language?
Experience: Has anyone in the family had experience with people of another culture? If yes, please explain.
Child's Health History
Does the youth applicant have any health issues that restrict his/her activities? Please elaborate. If there are no health issues, please write none.*
Does the youth applicant take prescription medications? If so, please elaborate. If there are no medications, please write none.
List any allergies and their severity or reactions. If none, please write none.
Please describe any other information about the youth applicant's mental or physical health, behavior or other information that the selection committee should know.
List adults who may participate on phone calls or group interchange activities. For each person, list name, age, relationship & languages spoken. CISV will conduct a background check of all people over 18 living in the home where youth are hosted.
Family Description
Please describe your family, especially considering the following: Individual and family interests and major activities, specific tastes in music, books, art, etc., food habits and preferences, anything else of interest for your partner Leader/Junior Leader
Please describe the ages, genders and other relevant information about other children and members of your family that would participate in the interchange.
Interchange Expenses

Interchange families are expected to cover their share of the expenses of the interchange such as the leader honorarium, any CISV program fees, and any charges for local in-peron activities. When necessary, parents must arrange for transportation for group activities.
Please check here to acknowledge that you have read and agree to observe CISV’s policy on interchange expenses.

Yes, I acknowledge.
Virtual Interchange participation requires commitments of time, energy, and interest before, during, and to a lesser extent, after both phases of the experience. Please describe your commitments and ability to participate?
Description of Youth
Please describe the youth applicant. This information will be used in assisting the Local Interchange Committee to match your child with a child from the other country. Your comments will also inform your child’s international interchange family about your child. Please include: Overall personality, temperament, needs and interests, relationship with each member of the family, relationship with others (peers, adults, relatives, elderly and young children), reaction to meeting new people and new situations, reaction to disagreement, familiarity and comfort with video conferences, and other factors that you believe should be considered in matching your child with an international partner.
Please describe your child (see the paragraph above for the topics).
Youth Delegate's Statement
Things I like to do are ...
I like...
I don't like . . .
I get angry about...
Other people love this about me...
Other people do not like this about me . . .
I can be happy about (something that does not cost anything) . . .
The ability I would like to have is . . .
If I were an adult, I would . . .
I expect my best friend to...
What else I want my Interchange partner to know...
Please describe typical things you might do with your virtual interchange partner:
NATIONAL CODE OF CONDUCT AGREEMENT

I do agree with my local CISV Chapter and the National and International officers of CISV to participate fully in the Interchange program.I will abide by the guidelines established by CISV International, INFO FILE R-7 (9008), in such manner that will enhance our life together and foster courtesy and understanding between us all. I understand I will be expected to participate in all CISV activities established as part of the virtual interchange (trainings, virtual meetings, any local in-person activities agreed to by the interchange families, asynchronous events, games, culture sharing, crafts, singing, dances, meetings and workshops, etc.) and I agree to participate to the best of my ability. I further agree to represent my CISV Chapter in a manner that is consistent with the values of my home, community and country.
IN SIGNING THIS APPLICATION, WE (APPLICANT AND PARENTS/GUARDIANS) CONFIRM THAT:
Acknowledgments*

We have read, understand, and agree to abide by the National Code of Conduct Agreement and the CISV USA Travel Policy.The information we have provided in this application may be verified by contacting individuals and agencies other than those listed in this application.We release and hold harmless any individual or organization that provides additional information about us to CISV. We also hold harmless any officers or volunteers of CISV International, CISV USA, or the local Chapter of CISV.All information provided on this application istrue and correct.
Signature of Parent/Guardian #1*

Clear
Date of Signature of Parent/Guardian #1

MonthDayYear
Signature of Parent/Guardian #2

Clear
Date of Signature of Parent/Guardian #2

MonthDayYear
Signature of Youth Applicant*

Clear
Date of Signature of Youth Applicant

MonthDayYear
Should be Empty:

Virtual Interchange Participant Application

Youth Applicant Information

Parent/Guardian Information

What are Parent's/Guardian's current volunteer activities?

Will you be able and willing to volunteer with CISV if your child is selected?

Child's Health History

Family Description

Description of Youth

Youth Delegate's Statement

NATIONAL CODE OF CONDUCT AGREEMENT

IN SIGNING THIS APPLICATION, WE (APPLICANT AND PARENTS/GUARDIANS) CONFIRM THAT: