ICMF VOLUNTEER HOST FAMILY APPLICATION

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: (O) _______________________ (H) __________________________
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:________________________________________________________________________________________________
________________________________________________________________________________________________________

Phone: (H)__________________(W)_____________________(Cell)____________________Email:_______________________

Dated this ________ day of __________, 2006.
NOTARY:

COUNTY OF: _______________STATE OF: ____________________________
MY COMMISSION EXPIRES: ____________________________________

Subscribed and sworn/affirmed to me this ________ day of _______________, 2006

NOTARY SEAL: