Interchange Delegate Application

Interchange Delegate Application Form

The information provided on this form will be used by the Local Interchange Committee to evaluate applicants and, if the youth is selected for interchange, pair the youth delegate with his/her 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
Gender Identity
Date of Birth of Youth Applicant*

MonthDayYear
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
School Principal's Name
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

Cancelof
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 travel. 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.
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.
Please describe the youth applicant's swimming ability

Youth applicant is a good swimmer.Youth applicant has some swimming ability.Youth applicant cannot swim.
Is the child fully vaccinated against Covid-19?

YesNo
Upload vaccine card

Browse Files

Cancelof
If your child is selected, a physician’s declaration of your child’s health and fitness for CISV participation will be required.
Travel experience with parents
Describe youth's travel experience(s) with parents
Describe youth's travel experience without parents
Living abroad experience (specify country, date, duration)
Which adults will look after the delegates during the interchange?
Do either or both parents/guardians speak another language?
List other people living in the home with the youth delegate. 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.
Domestic duties that will be expected of the youth delegate and his/her partner in your home
Animals that live in the home or outside
Is it a problem for youth applicant to be in a home with pets?

Yes. It is a problem for youth applicant to stay in a home with a pet.No. It is not a problem for youth applicant to be in a home with a pet.
If yes, which animals are a problem?
Religion: Specify if you want the delegate to attend religious services while being hosted, if possible. Of his/her own faith, or the host’s?
Experience: Has anyone in the family had experience with people of another culture? If yes, please explain.
Family Description
Please check which of the following you as a family most value and would hope that a guest would understand and take into account:

Mother-dominant homeFather-dominant homeCasual homeNeatnessMany individual pursuitsFamily-centered activitiesIntellectual interestsSports/outdoor activitiesReligious activitieslow-key, quiet homeIndividual privacyPlanned, organized homeOpenness of feelingEverybody pitches inMealtime togethernessHumorLots of communicationDecisions by consensusDecisions by parentsSpontaneityActive in community serviceOnly non-alcoholic beveragesActive, busy, sometimes noisy homeVegetarian or vegan cooking only
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
Hosting Description

Please describe your home and schedule during the Interchange, including the following: Type of home (single family detached house or multi-family apartment building, in the city or in the country, etc.) Will your guest have his/her own room, or share? (If sharing, with whom?) Will your guest have his/her own bed or share? (If sharing, with whom?) Recreational facilities available (musical instruments, swimming pool, fitness center, distance from downtown or community center, etc.) Transportation: public or private? Car, bus, train? What would your family do on a typical summer day?
Please describe your home and schedule (see paragraph above for topics to be covered):
Reciprocal Hospitality

The hosting family is to pay expenses for the visiting youth delegate, in the same way as for their own child (e.g. the cost of the group’s hosting activities, as well as transportation, sightseeing, trips and meals that are not part of the group’s hosting calendar). This will include meals, transportation, sightseeing, and Family Week trips. Personal expenses should be paid by the visiting delegate from his/her own pocket money. 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 Interchange policy on reciprocal hospitality, found in the Interchange Guide and stated above.

Yes, I acknowledge.
Interchange participation requires substantial 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?
NATIONAL TRAVEL POLICY

1) Village, Step Up, and Interchange delegations shall travel to and from the site of the approved CISV activity as a group. Travel shall be direct and continuous to and from the CISV activity site. No side trips shall be permitted. No layover in excess of 24 hours shall be permitted unless common carrier schedules require otherwise. Delegation itineraries must be approved by the local Chapter. 2) Penalties - Violations of Section 1 will result in disciplinary action against the Chapter or Steering Committee pursuant to the complaint procedure (83-BOT-2) of CISV, Inc. 3) Individual travel (as in the case of Junior Counselors and Seminar Camp and Youth Meeting participants) other than to and from the site of an approved CISV activity shall be deemed non-CISV travel. CISV assumes no responsibility or liability for an individual while on a side trip or layover in excess of 24 hours.
Yes. I acknowledge and agree to CISV's national travel policy.
Description of Youth
Please type below, as honestly and fully as possible, about the youth applicant. This information will be most helpful in assisting the Local Interchange Committee to place your child in the best environment to encourage growth, learning and sharing. Your comments will also inform your child’s host family abroad 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, reactions to being away from family in the past, factors that you believe should be considered in placing your child in a new environment
Please describe your child (see the paragraph above for the topics).
Youth Delegate's Statement
I like...
My hobbies are...
I don't like . . .
I get angry about...
Other people love this about me...
Other people do not like this about me . . .
I wish . . .
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 . . .
When I am sad, this helps:
I expect my best friend to...
What else I want my Interchange partner to know...
Please describe typical things you might do with your 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 will not bring or use illegal drugs. If I am under the age of 18 and smoke, I will bring a signed letter of consent from my parents or guardians. If I am in a country where there is no legal age for drinking and I am under 21, I will furnish a signed letter of consent from my parents or guardians. In all cases I will observe the wishes of my host family regarding drinking and smoking as a matter of courtesy. I will observe such sexual mores and behaviors that will not embarrass or injure others (such behaviors having been discussed with my parents/guardians). I understand I will be expected to participate in all CISV activities (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.
Click here to access the CISV R-07 Behaviour Policy referenced above.
IN SIGNING THIS APPLICATION, WE (APPLICANT AND PARENTS/GUARDIANS) CONFIRM THAT:
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:

Interchange Delegate Application Form

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?

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.

Child's Health History

Travel experience with parents

Family Description

Hosting Description

NATIONAL TRAVEL POLICY

Description of Youth

Youth Delegate's Statement

NATIONAL CODE OF CONDUCT AGREEMENT

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