Adopt-a-Student

Conact Information

First Name

Last Name

Cell Phone Number

Email

Zip Code

__________________________________________________

General Information - This information helps us match mentors and host families with students who have similar interests and desires when possible

Are you applying as a mentor (individual) or host family (couples and families with children)?
MentorHost Family

Would you be more comfortable with male or female student?
MaleFemaleNo Preference

Are you interested in adopting more than one student?
YesNo

What local church do you attend?

Occupation and Educations

About you - hobbies/interests, community/organizations, etc.

Do you have any pets? If so, what kind?

Does your household have any restrictions due to COVID? If so, please explain.

__________________________________________________

Household Information

Photo of you/your household

Name of Spouse/Housemate(s)

Occupation and Educations of Spouse/Housemate(s)

Name(s) and Age(s) of Children Living at Home

Name(s) and Age(s) of Children not Living at Home

____________________________________________

Personal References - Please provide information for two personal references. One reference must be a church pastor/leader.

Reference 1 First Name

Reference 1 Last Name

Reference 1 Phone Number

Reference 1 Email

Reference 2 First Name

Reference 2 Last Name

Reference 2 Phone Number

Reference 2 Email

______________________________________________

Completed Code of Conduct Form

Completed Responsibility Contract

Are you willing to consent to a background check? There is a $10.00 fee associated for each screening.
***If you are applying as a mentor, only you will need to consent to a background check. If you are applying as a host family, everyone in your household 18 years and older will need to consent to a background check.
YesNo

Any other information you would like to share?

Δ