ICMF VOLUNTEER HOST FAMILY APPLICATION
For A Downloadable PDF Copy Of This Volunteer Host Family
Any Questions: ICMFHope@Aol.Com
Print, fill out (and) along with two passport size photos, mail to:
International Children's Medical Foundation
PO Box 770795
New Orleans, LA (70117)
First Name:___________________________________ Age:__________
Spouse:______________________________________ Age: ________
Status: M S D W
Office: _________________________________________________ Home:
Fax:_______________________ Email: ______________________
Employer: ___________________________________________________ Address:
Do you have other children in your home?______________
Names and Ages: ______________________________________________________________
Will you need to employ outside help (babysitter) while child is in your home?____________
What experience, if any, do you have in caring for a medically needy child?
Why do you want to host a medically needy child?_____________________________________________________________
What Children's Hospital or Medical Schools are in your
How many miles (one way) would you be prepared to drive to take a medically needy child to post op medical
If necessary, how many times a week would you be prepared to make such a trip?
Do you feel you would have difficulty in "letting the child go" when it is time for the child to leave your home?
If yes, please explain: ________________________________________
ICMF's Host Families are given a notarized "limited" Power of Attorney, authorizing the Host Family to take the
child to medical treatments as well as sign for any emergency medical care that may arise. Would you be prepared to furnish
your notarized signed signature to the following document?
HOST FAMILY AGREEMENT
I/we,________________________________________________________ have read the Power of Attorney presented to
me/us regarding ____________________________________________________________
I/we agree to act as Host Family for ___________________________ and to abide by the Power of Attorney.
I/we understand _____________________________________________ is not up for adoption and that he/she will return to his/her native country upon
completion of his/her medical treatment.
I/we understand I/we are doing this as a voluntary act and there is no monetary benefit for me/us. I/we
understand all medical care is taken care of with INTERNATIONAL CHILDREN'S MEDICAL FOUNDATION (hereafter called "
ICMF"), scheduling all surgical appointments), and (that) my/our responsibility is to take
to all pre/post surgical medical appointments and provide his/her food, clothing and lodging while guest in
I/we understand _____________________________________________
is known at home as _________________________________________ and will address him by that name and not another
"nickname," "pet name" nor any other "terms of endearment."
I/we agree not to permit any multi-media news coverage regarding
____________________________________________________________'s stay in the U.S. without prior written permission
I/we agree to fully protect ____________________________________ and his/her family in his/her native
country by not using his/her last name outside of our home except as needed with doctors, hospitals, etc. and being satisfied in not knowing the name of
his/her town/ village.
I/we further understand ICMF is _______________________________'s legal guardian and agree to release
__________________________ back to ICMF at any time requested to do so, whether medical treatment is completed or
If the necessity of legal action arises as a result of my/our actions against
ICMF and/or any/all of ICMF´s staff volunteer(s) I/we agree to pay all attorney's fees and court costs in behalf of
ICMF and/or any/all of ICMF´s staff volunteer(s).
(If two parents, both must sign).
Dated this ________ day of __________, 200___.
COUNTY OF: _________________________________________________
STATE OF: __________________________________________________
MY COMMISSION EXPIRES: ____________________________________________________________
Subscribed and sworn/affirmed to me this __________________ day
of _________________________________________, 200________