Forms

 
 

Ready to take the next step? Fill out the forms electronically (preferred) below to get started or download the completed forms by clicking the buttons below, print, sign and email to masoncountyhost@gmail.com (pdf or jpg file).

Host Home Transitions Program

Student Application Form

Date
Date
Name *
Name
First, middle and last required
Phone Number
Phone Number
Alternative Phone Number
Alternative Phone Number
Cell Phone Number
Cell Phone Number
Current Housing Address
Current Housing Address
How has your housing situation affected your education? Please give as complete a response as possible (ie. homelessness, medical concerns or issues, addition, lack of food, etc.).
Have you identified a supportive person in your life with whom you could live? If so, please include that person's name and contact information below.
Support Person's Name *
Support Person's Name
First and last required
Support Person's Address
Support Person's Address
Support Person's Phone Number
Support Person's Phone Number
Would you be interested in living with a HOST family from the community? *
Have you ever lived in a Group home? *
Enter dates: From To
Have you been in Foster Care? *
From To
Expected graduation date
Expected graduation date
Employment/Income/ Financial Information: List monthly income amounts you may be receiving: *
Do you have any of the following? IF so please list amount: *
Employer Name Position Dates Employed Reason for leaving Salary
Have you ever participated in counseling or therapy? *
Have you been/are you currently a victim of physical, sexual, or emotional abuse? *
Do you smoke cigarettes? *
Do you use alcohol? *
Have you ever participated in an alcohol or treatment program? *
Treatment program dates *
Treatment program dates
Have you ever been convicted of a crime? *
If yes, have you ever been in juvenile detention, jail or prison? *
Facility/Location Name
Are you or have you been on probation or parole? *
Probation or parole start date:
Probation or parole start date:
Probation or parole end date:
Probation or parole end date:
Probation/ Parole Officer's Name
Probation/ Parole Officer's Name
What type of transportation do you rely on? *
Applicant Signature
Applicant Signature Date
Applicant Signature Date

HOST Home Program

Host Application Form

Demographic Information

Applicant A Name *
Applicant A Name
First, middle and last required
Work Phone *
Work Phone
Date of Birth *
Date of Birth
Applicant B Name *
Applicant B Name
First, middle and last required
Work Phone *
Work Phone
Date of Birth *
Date of Birth
Household Information - Address *
Household Information - Address
Contact Phone *
Contact Phone
Check all that apply *
Applicant A - Do you have a current Washington State drivers license? *
Applicant B - Do you have a current Washington State drivers license? *
Do you have renters/homeowner insurance? *
Can you provide a private room/space for a youth? *
Are you planning on moving within the next year? *
List two references (non-relatives) you have know at least 1 year and one reference whom you have known for 5 years. If you are applying with another person(s), your references should know each person and how you function as a family/community
Reference 1 - Name *
Reference 1 - Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Reference 2 - Name *
Reference 2 - Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Members of Household - 1 *
Members of Household - 1
(Include roommates, relatives, children and others in home)
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Members of Household - 2 *
Members of Household - 2
Date of Birth *
Date of Birth
Date of Birth *
Date of Birth
Date of Birth *
Date of Birth
Do they have concerns? *
Have you ever been a convicted of a crime? *
This doesn’t rule you out of becoming a host home volunteer
Have you ever been a licensed as a foster parent? *
This is not a requirement for the Rotary Host Home Program.
Electronic Signature Applicant A *
Electronic Signature Applicant A
Date *
Date
Date *
Date