Host Application

/Host Application
Host Application2019-09-16T17:28:27+00:00

Host Application

  • Host Family Information

  • Host Father

  • Date Format: MM slash DD slash YYYY
  • Host Mother

  • Date Format: MM slash DD slash YYYY
  • Children In Your Home

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Others Living In Your Home (please include relatives, roommates, live in nannies):

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Pets/Animals

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Price: $100.00
  • Legal Information

    If the answer to any of the following questions is “yes”, please provide a detailed explanation in ——the space below or on a separate sheet of paper. Answering yes does NOT automatically disqualify you from participating in the Hosting Program. Failure to disclose material information could make you ineligible to complete the hosting process.
    NOTE: Include any traffic offenses such as DUI and Suspended License
  • Have you ever been questioned, arrested, charged, and/or convicted of any crime including but not limited of shoplifting, fraud, theft, prostitution, solicitation, DUI, DWI, domestic violence, child abuse, assault, or possession of a controlled substance,

    Have you ever been questioned, arrested, charged, and/or convicted of any crime including but not limited of shoplifting, fraud, theft, prostitution, solicitation, DUI, DWI, domestic violence, child abuse, assault, or possession of a controlled substance,
  • Respond “yes” even if you were not involved or if you initiated the “complaint”.

    Respond “yes” even if you were not involved or if you initiated the “complaint”.
  • ls there any reason that you would not be approved for FBI, State background and/or a child abuse Clearance ?

    ls there any reason that you would not be approved for FBI, State background and/or a child abuse Clearance ?
  • Do you have a history of—drug or alcohol abuse?

    Do you have a history of—drug or alcohol abuse?
  • Has your application to host, adopt or foster parent ever been rejected by any other host organization, adoption, foster or child-placing agency?

    Has your application to host, adopt or foster parent ever been rejected by any other host organization, adoption, foster or child-placing agency?
  • Have you ever been subject to an unfavorable home Study?

    Have you ever been subject to an unfavorable home Study?
  • Have you ever had parental rights terminated by a court at low?

    Have you ever had parental rights terminated by a court at low?
  • Home Study

  • Hosting Preferences

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Child Safety Agreement

    This section contains information about the safety of children placed in your care during hosting. Your signature indicates your acknowledgment and agreement with the safety requirements for host homes as stated below.
    As children are the primary victims of animal bites, I/we agree to comply with the following mandates listed below to assure the safety of any child placed in my/our home:.
    •Provide close supervision of children when around animals.
    •Refrain from keeping dangerous or aggressive dogs/pets, in the home, unless properly secured with a leash, fence or cage, etc.
    Firearms take the lives of thousands of children each year. To prevent the accidental death of any child placed in my/our home, I/we agree to the following mandates: •Secure all firearms in my/our home under lock & key using a commercial brand trigger safety locks available for this purpose. •Keep all firearms unloaded and out of the view and reach of children in the home. •Never allow children placed in the home to handle guns.
    Children in care are always required to be supervised by appropriate adult caretakers. In keeping with this requirement, I/we agree to adhere to the following: •Provide appropriate adult supervision for the children in my/our care at all times •Refrain from leaving children placed in my/our care in the supervision of minors. •Refrain front leaving children unattended in a motor vehicle.
    Motor vehicle accidents are the leading causes of death for children of all races, ages 5-14, according to national statistics. To ensure the safety of children placed in my/our care, I/we agree to adhere to the following safety precautions while riding or driving motor vehicles:
    •Secure children 4 and under in federally approved child safety restraint seat properly installed to manufacturer’s instructions.
    •Secure children over 4 years of age in the rear seat of the vehicle with federally: approved and properly installed safety seat belts or appropriate car seat Refrain from transporting children/youth under 18 years of age in the bed of a pickup truck at any time. Children must always be properly secured with safety belts
    •Ensure direct adult supervision of children when around bodies of water
    •Ensure compliance with any local or state ordinances regarding pools or waterfront property.
    •Secure entire perimeter of the pool area with a fence and locked gate of sufficient height to prevent the entry of young children.
    NOTE: Home‹ with ponds, or homes located on waterfront property, are required to employ substantive safety measures to ensure the protection of children in the home.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Discipline Policy

    prohibit the use of corporal or unusual punishment on a child in the home.

    To ensure the safety and well-being of the children placed in my/our home, I/we agree to the following:
    •Refrain from the use of any corporal or unusual punishment on a child placed in my/our home, including, but not limited to the following: spanking, slapping, switching, shaking. pinching, biting, twisting, or pulling, tying with rope, withholding food, force-feeding, denying appropriate contact with chaperones. or country representative, degrading child’s country, foster family or culture, or humiliating chi/d: creating fear, anger, and anxiety, locking child in a room, closet or outside the home: group punishment or delegating older children of administer punishment, destroying the child’s properly and any other practices which may physically or emotionally damage the child.
    •Seek on-going information/training to build and enhance my/our child behavioral
    •Immediately inform lifeline of assistance needed in managing the behavior of a child placed in my/our home, during host period.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Final Signature

    I/we agree to the following:
    •We have provided truthful and accurate information on this application.
    •We will provide any information requested by Lifeline or the governing agency as requested.
    •We will submit the online background check request with in 48 hours of submitting this application.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY