BACKGROUND CHECK FORM

I hereby authorize the _______________________________________

Chapter/Steering Committee of Children's International Summer Villages, Inc. to do a

background check on me: ,

1. Criminal Record including "Physical/Sexual Abuse."

2. Motor Vehicle Report for my driving record.

This information will be used to determine eligibility and insurability as an adult volunteer Interchange/Village host as required by the board of Trustees of CISV USA and the United National Insurance Company. This information will be kept confidential and will be reviewed periodically.

As of the 12/01/01 Liability Policy renewal, the Insurance carrier mandates the following:

1. That no one under the age of 26 transport participants to, from or during ANY CISV activity.

2. That evidence of your Personal Auto Policy with minimum limits of liability totaling

$100,000 (each person Bodily Injury limit + Property Damage limit = $100,000 total)

be on file with the Chapter/Steering Committee.

3. That Motor Vehicle Reports must be updated annually.

Recommendation: That both the Criminal Record and Motor Vehicle Reports be filed by the Chapter/Steering Committee and retained for 14 years.

PRINT FULL NAME___________________________________________________

SOCIAL SECURITY NUMBER ______________________________________________________________________________

DRIVER'S LICENSE NUMBER & STATE ___________________________________________________

DATE OF BIRTH _____________________________________________________________

DATE_______________SIGNATURE__________________________________________