Name
*
First Name
Last Name
How do you identify?
Check all that apply.
I feel comfortable discussing:
Sexual Orientation
Gender Identity
Power & Privilege
Racial Justice
Mental Health
Substance Use & Abuse
Do you speak any languages other than English? If so, what languages?
Do you smoke?
Yes and I smoke in our home
Yes, but I don't smoke in our home
No, I don't smoke
Do you drink alcohol?
Yes, but I don't drink in the home
Yes and there's alcohol in the home
No I don't drink
Do you use any other substances?
Please tell us why you're interested in hosting a young person in your home:
Please describe the characteristics of a young person you would wish to host:
Pleaes describe any characteristics of a young person you would not wish to host:
Is there anything else you'd like to tell us about yourself?
Gender, race, ethnicity, class, ability, strengths, skills, etc.
Please describe any physical and/or mental health concerns in your family that could impact someone living in your home:
Have you ever been arrested by a law enforcement officer?
Yes
No
Have you ever been legally charged with an offense?
Yes
No
Have you ever been convited of any offense?
Yes
No
Have you ever been charged with or convicted of an offense against a minor?
Yes
No
Have you ever abused, neglected, or molested any minor?
Yes
No
If you answered "yes" to any of the above, please explain:
Are you currently employed? If so, where? If not, do you have a stable source of income?
I certify that the facts contained in this application are true and complete to the best of my knowledge. Please e-sign in the box below:
*
Today's Date
MM
DD
YYYY
