HOST FAMILY AGREEMENT & ORIENTATION
(For Adults hosting youth and adults participating in CISV programs- PLEASE COMPLETE ALL INFORMATION)
CISV Homestay Goals
Thank you for choosing to be a host family for CISV visitors from all over the world. CISV's mission is to educate and inspire action for a more just and peaceful world. By being a host family for Interchange or for a homestay weekend for CISV camp participants, you participate in that mission. As an interchange family, your efforts are vital to achieving the educational goals of an interchange, which are to (1) increase awareness of the cultures in an Interchange, (2) develop self-reliance while hosting or living with someone from another culture, (3) learn how to work cooperatively and have a positive attitude towards others, and (4) learn to behave as a responsible active global citizen. The purpose of homestay weekends is to introduce the visiting CISV delegates to USA culture, as well as to give them some time to relax in a family setting. It gives you and your family a sense of what CISV is about: learning from each other and sharing our cultures to achieve a more harmonious world.
Child Safety and Protection
The safety of each child in CISV's care is paramount. CISV International has comprehensive child protection policy and procedures, which are reviewed and updated regularly. CISV USA additionally has their own child protection procedures, which are in line with USA national legislation and requirements. As part of these procedures, we conduct home visits, background, drivers and insurance checks, and host parent training. CISV requires a criminal background check on host families, leaders, staff and adult chaperones every two years and a motor vehicle records check for all eligible drivers every year. Thank you for answering the questions in this form and helping us comply with our child protection policies.
CISV Chapter Requesting Information
CISV Atlanta
CISV Austin
CISV Boston
CISV Brandywine Valley
CISV Chattanooga
CISV Cincinnati
CISV Columbus
CISV Dallas/Ft Worth
CISV Detroit
CISV Greater Springfiel
CISV Gulf Coast
CISV Jacksonville
CISV Maine
CISV Miami FL
CISV Miami County OH
CISV Michigan City
CISV Northeast Ohio
CISV New York
CISV Philadephia
CISV Portland
CISV Rocky Mtn Denver
CISV San Francisco
CISV Smoky Mtn
CISV Southwest Florida
CISV Washington
Date Requested
-
Month
-
Day
Year
Date
Name of Person Completing Form
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Driver's License Number
State Issuing Drivers License
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Address of Person Completing Form
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years at Address
Other Names Used
Are you accustomed to dealing with dietary restrictions? If so, describe which types (i.e., vegetarian, vegan, dairy-free, gluten-free, etc.)
Do you have pets in your home? If so, list type and number.
Criminal Record
Have you ever been convicted of or pleaded guilty or nolo contendere to a felony?
Yes
No
Have you ever been convicted of or pleaded guilty or nolo contendere to a misdemeanor (including DUI convictions)?
Yes
No
Have you been restrained or enjoined by a court injunction or order?
Yes
No
If yes to any of the above, please describe, including dates, location (city, county, state), nature of violation, details of any injunction or court order (attach additional sheets if necessary):
Automobile Insurance
Name of Auto Insurance Carrier
Auto Insurance Policy Number
Upload auto liability declaration page showing liability insurance of at least $100,000 each accident bodily injury and property damage coverage;
Browse Files
Cancel
of
Background Checks
CISV conducts background checks on every "adult" that will have unsupervised access to the participants, which includes all 18+ individuals living in your home, providing caretaking for the participants or visiting the home unsupervised. For instance, if your home will include college kids home for the summer or grandparents/aunts/uncles staying in the home or in attached units, background checks must be conducted.
Please name other adults (age 18+) living in your home
Consent for Release of Information
I certify that the information provided by me in this questionnaire is true and correct. I understand that any falsification, misrepresentation, misleading statement, or omission of fact will be sufficient reason for refusal to allow me to serve as a CISV volunteer. I further acknowledge and agree that this information may be used to determine my eligibility to serve as a volunteer in connection with CISV’s programs and activities. I hereby authorize CISV USA (including its Chapters) to perform a complete background check on me, including without limitation a complete criminal record check and motor vehicle driving record check, and to perform additional background checks on me from time to time. I further authorize CISV USA to release my name, date of birth, driver’s license number, and state in which that license was granted to CISV USA’s liability insurance carrier, with the understanding that the carrier may, at its discretion, perform its own motor vehicle records check. I hereby release CISV USA and its Chapters, steering committees, officers, directors and volunteers from any claim or liability arising out of the performance of these background checks. I further acknowledge that I have been advised of and agree to comply with CISV’s policies in connection with the use of a motor vehicle to transport CISV participants, including that any person transporting CISV participants in connection with a CISV program must: • Be 23 years old or older*; • Carry automobile liability insurance with minimum limits of at least $100,000 (per accident for bodily injury and property damage) and provide proof of such insurance to CISV; • Have a clean driving record (no serious infractions and no more than two minor infractions).
Applicant's Signature to consent to release of information.
Name
First Name
Last Name
Consumer Reports Disclosure
We are required by U S. law – the Fair Credit Reporting Act and its amendments, 15 U.S.C §§ 1681-1681u – to notify you that CISV USA, its chapters, steering committees and/or its agents (collectively, “CISV”) may request an investigative consumer report from a consumer reporting agency for the purpose of evaluating your suitability to serve as a CISV volunteer. CISV would request this report as part of our routine background check procedures.The Fair Credit Reporting Act defines a consumer report, in part, as a report bearing on an individual's creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This includes, but is not limited to criminal and driving records, educational history, and prior employment verification. The report may contain information gathered from public or private sources. For further information you can review a document prepared by the Federal Trade Commission entitled “A Summary Of Your Rights Under The Fair Credit Reporting Act” at this link: http://www.ftc.gov/bcp/edu/pubs/consumer/credit/cre35.pdf. You have the right under the Fair Credit Reporting Act to receive from LexisNexis a description of the nature and scope of any consumer report that CISV requests. LexisNexis can be reached at 1-800-845-6004.
Authorization to Obtain Consumer Report
I have read the foregoing Consumer Reports Disclosure and understand its contents. I hereby authorize CISV to request and obtain the above-referenced consumer report at any time prior to or during my service as a CISV volunteer.
Applicant's Signature to authorize CISV to obtain consumer report
Name
First Name
Last Name
Acknowledgement of CISV Child Protection Policy
CISV believes that the welfare of children is the highest priority and that it is the responsibility of everyone in CISV to ensure they are protected. The child protection policy below sets out CISV's commitment to Child Protection and aims to promote good practics in (1) providing children with appropriate safety and protection while in the care of CISV and (2) allowing volunteer and staff to make informed and confident reponses to specific Child Protection Issues. Please sign below to acknowlege the terms of the policy. You can also access the policy here: https://cisv.org/resources/risk-management-travel-insurance/child-protection/
Signature to Acknowledge your Receipt and Agreement to Abide by CISV Child Protection Policy
Name
First Name
Last Name
Acknowledgment of CISV USA Sexual Abuse Prevention Policy
CISV USA is committed to providing a safe environment for all children. We recognize the importance of preventing sexual abuse and have adopted this Sexual Abuse Prevention Policy to demonstrate our absolute and unwavering commitment to ensuring that our programs offer a safe and nurturing environment for all participants. Please review the policy available below and sign the acknowledgement. You can also access the policy at this link: https://jacksonville.cisvusa.org/?page_id=1141&preview=true
Sign below to acknowledge your receipt and agreement to abide the CISV USA Sexual Abuse Prevention Policy.
Name
First Name
Last Name
CISV Behavioral Standards
Appropriate behaviour is expected of all CISV members in every part of CISV in order to support and accomplish: • CISV’s mission to educate and inspire action for a more just and peaceful world • CISV’s educational goals and methods• the expectations of participants and volunteers. Appropriate behaviour is defined as peaceful conduct that follows local laws and good manners; it is in line with what can be expected from a good host, guest, friend or role model. CISV Behavioural Standard are available below and at this link: https://cisv.org/resources/risk-management-travel-insurance/
Name
First Name
Last Name
Please sign to acknowledge and agree to abide by the CISV Behavioural Policy
Name of Person Completing Form
First Name
Last Name
Email
example@example.com
Restrictions on Certain Activities While Hosting
To reduce risk of injury, CISV participants should not use a trampoline. Host families who personally own and operate their own watercraft must have primary boat liability insurance in effect and should verify this coverage with their insurance agent. Our general liability policy excludes coverage for watercraft over 26 feet in length. CISV travel insurance does not cover injuries arising from motorcycle riding, scuba diving, skiing, mountain climbing, sky diving, hang gliding, paragliding, professional or amateur racing, or piloting an aircraft.
Are you accustomed to dealing with allergies? If so, please describe (i.e., nut-free, dust, pollen, etc.)
Please describe an activities you plan during the host phase that involves hiring watercraft (including rafting).
Date of Signatures
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: