Host Home Application

Step 1 of 6

Applicant Details

Initial application for host home providers. We have security in place to encrypt and protect your information. However, if you would like to leave any sensitive information blank, we can fill that in later.

Name

First

Last

Co- Applicant Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Directions to home

What type of youth are you interested in having in your home (age, sex, issues)

Applicant:

Date of Birth

Oregon Drivers License

Education – Last Grade Completed

Present Employer

Occupation

Work Phone

Occupational Education and Training

Previous Related Experience

Interests, Skills, and Hobbies

Save and Resume Later

References

Please list below four references (only one may be a relative), which have known you well as an individual, couple, or family, for at least two years. Tell them in advance that you are using them as references, and they have to be willing to answer questions regarding your character and parenting ability.

Reference 1 – Name

First

Last

Reference 1 – Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 – Phone

Reference 1 – Phone secondary

Reference 2 – Name

First

Last

Reference 2 – Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 – Phone

Reference 2 – Phone secondary

Reference 3 -Name

First

Last

Reference 3 – Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3 – Phone

Reference 3 – Phone secondary

Reference 4 -Name

First

Last

Reference 4 – Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 4 – Phone

Reference 4 – Phone secondary

Save and Resume Later

Applicant Details

Applicant:

Co Applicant

List all members of household

Emergency Contacts

References

Signatures