host family application form

ICMF VOLUNTEER HOST FAMILY APPLICATION

Click Here   For A Downloadable PDF Copy Of This Volunteer Host Family Application Form

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)

Last Name:__________________________________________________

First Name:___________________________________ Age:__________
Spouse:______________________________________ Age: ________

Status: M S D W
Address: ___________________________________________________

City: _______________________________________________________

State:__________ Zip:___________________

Phone:                                                                                        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 area?_____________________________________________________________
____________________________________________________________

How many miles (one way) would you be prepared to drive to take a medically needy child to post op medical treatments?_____________________________________________________________

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 my/our home.

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 from ICMF.

 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 not.

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).

HOST FAMILY:

(If two parents, both must sign).
Signature:____________________________________________________

Print Name:________________________________________________________

Signature: _____________________________________________________________

Print Name:_______________________________________________________

Address:_____________________________________________________
City: ________________________________________________________

State: ____________________       Zip:_____________

Dated this ________ day of __________, 200___.

NOTARY:

COUNTY OF: _________________________________________________

STATE OF: __________________________________________________

MY COMMISSION EXPIRES: ____________________________________________________________

Subscribed and sworn/affirmed to me this __________________ day

of _________________________________________, 200________

NOTARY SEAL: