Host Parent Application Full

Applicant 1 First Name *

Applicant 1 Last Name *

Are you applying with someone else? *

Yes

Applicant 2 First Name

Applicant 2 Last Name

Home Address *

Street Address Line 2

City *

State/Province *

Zip Code *

Do you live in a:

House

Multi-unit building

Home Phone

Home Fax

Number of Bedrooms *

District/County

Applicant 1 Information

Please fill in the information below about yourself

Birth Date *

Month

Day

Year

Are you a U.S. Citizen?

Yes

Current Employer *

Job Title *

Business Address *

Street Address 2

City *

State *

Zip Code *

Office Phone

Office Fax

Cell Phone *

Primary Email *

Applicant 2 Information

Please fill in the information below about the person you are applying with

Birth Date

Month

Day

Year

Are you a U.S. Citizen?

Yes

Current Employer

Job Title

Office Phone

Office Fax

Cell Phone

Are you (Applicant 1 and Applicant 2) married?

Yes

Applicant 1 Previous Marriages

Applicant 2 Previous Marriages

Children and Family Information

Do you have any children living in your home? *

Yes

Please provide the information for the children living in your home

Child 1

First Name

Last Name

Gender

Birth Date

Month

Day

Year

If adopted, date of finalization

Month

Day

Year

Do you have any additional children?

Yes

Child 2

First Name

Last Name

Gender

Birth Date

Month

Day

Year

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Do you have any additional children?

Yes

Child 3

First Name

Last Name

Gender

Birth Date

Month

Day

Year

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Do you have any additional children?

Yes

Child 4

First Name

Last Name

Gender

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Birth Date

Month

Day

Year

Do you have any children living outside of your home? *

Yes

Child 1

First Name

Last Name

Gender

Birth Date

Month

Day

Year

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Do you have any additional children living outside your home?

Yes

Child 2

First Name

Last Name

Gender

Birth Date

Month

Day

Year

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Do you have any additional children living outside your home?

Yes

Child 3

First Name

Last Name

Gender

Birth Date

Month

Day

Year

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Do you have any additional children living outside your home?

Yes

Child 4

First Name

Last Name

Gender

Relationship to Applicant 1 Date of Adoption Finalization

Month

Day

Year

Birth Date

Month

Day

Year

Are there any other adults living in your home? *

Yes

Adult 1

First Name

Last Name

Relationship to Applicant 1 Relationship Type(s)

Parent of

Sibling of

Roommate Of

Family Member (Other) Of

Are there any other adults living in your home?

Yes

Adult 2

First Name

Last Name

Relationship to Applicant 1 Relationship Type(s)

Parent of

Sibling of

Roommate Of

Family Member (Other) Of

How did you hear about Family & Youth Initiative? *

Why did you decide to become a host parent?

References

Please list three people who know you well (excluding relatives or clergy); note that all references will be contacted by phone and one will be interviewed in person:

Reference 1

First Name

Last Name

Street Address

Street Address Line 2

City

State/Province

Postal Code

Phone Number

Reference 2

First Name

Last Name

Street Address

Street Address Line 2

City

State/Province

Postal Code

Phone Number

Reference 3

First Name

Last Name

Street Address

Street Address Line 2

City

State/Province

Postal Code

Phone Number

If you have a child or children living in your home who is attending school, please list below a reference who is a teacher, administrator, or counselor employed by one of the schools attended by one of your children

First Name

Last Name

Street Address

Street Address Line 2

City

State/Province

Postal Code

Phone Number

If you answered yes to any of the above questions, please complete:

Name of Agency *

First Name *

Last Name *

Phone Number *

I/we are interested in hosting a child in the Family & Youth Initiative program and am/are aware that all of the children will have issues that will need time and attention. I/we understand that older children in foster care may have some delays in development and may have other medical or psychological issues that will require attention and care, both emotionally and financially.

Family & Youth Initiative and its partners are required by law to deny this application if any of the information provided is known to be false or misleading by the applicant.

By providing your name(s) below you are certifying that the information you have entered is true.

Name of Applicant 1 *

Name of Applicant 2

Signed Date *

Month

Day

Year

Leave this field blank

DCFYI

Applicant 1 Information

Applicant 2 Information

Children and Family Information

References

Reference 1

Reference 2

Reference 3

Status

If you answered yes to any of the above questions, please complete:

Personal Information Applicant 1

Personal Information Applicant 2

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