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?
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