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).

STUDENT APPLICATION FORM DOWNLOAD

HOST APPLICATION FORM DOWNLOAD

Host Home Transitions Program

Student Application Form

Date

YYYY

Name *

Name

First, middle and last required

First Name

Last Name

Gender Identity *

Preferred Pronouns *

Sexual Orientation *

Race *

Email Address *

Phone Number

(###)

###

####

Alternative Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

Current Housing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Housing

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.).

Housing 2 *

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

First Name

Last Name

Support Person's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Support Person's Phone Number

(###)

###

####

Would you be interested in living with a HOST family from the community? *

Yes

How long have you lived in Mason County?

Have you ever lived in a Group home? *

Yes

If yes, please enter dates lived in a Group home below.

Enter dates: From To

Have you been in Foster Care? *

Yes

If yes, please enter dates below. *

From To

Reason for entering Foster Care

Education - Current School

Grade

Expected graduation date

YYYY

Name of Guidance Counselor

How many High School credits have you earned?

Employment/Income/ Financial Information: List monthly income amounts you may be receiving: *

TANF $

Food Stamps $

SSI $

Employment $

Other $

None

Do you have any of the following? IF so please list amount: *

Checking account $

Savings account $

Credit card debt $

Cell phone bills $

Owed rent/utilities $

Medical/hospital bills $

Please List Current/ previous employment:

Employer Name Position Dates Employed Reason for leaving Salary

Personal Information

Have you ever participated in counseling or therapy? *

Yes

Have you been/are you currently a victim of physical, sexual, or emotional abuse? *

Yes

Do you smoke cigarettes? *

Yes

If yes, how many cigarettes per day?

Do you use alcohol? *

Yes

Text If yes, how many times per day/week? *

Including prescribed medications, are you currently using any prescribed or illegal drugs? If yes, please list type and frequency of use:

Have you ever participated in an alcohol or treatment program? *

Yes

If yes, what kind?

Treatment program dates *

Treatment program dates

YYYY

Legal Information

Have you ever been convicted of a crime? *

Yes

If yes, when and how many times?

If yes, have you ever been in juvenile detention, jail or prison? *

Juvenile Detention

Jail

Prison

Facility/Location *

Facility/Location Name

Are you or have you been on probation or parole? *

Yes

Probation or parole start date:

YYYY

Probation or parole end date:

YYYY

Probation/ Parole Officer's Name

First Name

Last Name

Additional Information

What type of transportation do you rely on? *

Public transportation

Walking

My own car

Another driver/borrowed car

I affirm that the answers I have provided on this application are true and correct, and that I have not knowingly withheld any information that if disclosed would affect my application unfavorably. I further understand that any false information submitted on this application and during the application process may result in my not being considered for the HOST Home Transitions Program or may result in my discharge from a residential placement. *

Applicant Signature

Applicant Signature Date

YYYY

Thank you!

HOST Home Program

Host Application Form

Demographic Information

Applicant A Name *

Applicant A Name

First, middle and last required

First Name

Last Name

Occupation *

Work Phone *

Work Phone

(###)

###

####

Email Address *

Date of Birth *

Date of Birth

YYYY

Race *

Gender Identity *

Pronoun Used *

Sexual Orientation *

Applicant B Name *

Applicant B Name

First, middle and last required

First Name

Last Name

Occupation *

Work Phone *

Work Phone

(###)

###

####

Email *

Date of Birth *

Date of Birth

YYYY

Race *

Gender Identity *

Pronoun Used *

Sexual Orientation *

Household Information - Address *

Household Information - Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone *

Contact Phone

(###)

###

####

Check all that apply *

Rent

Own

Apartment

House

Cooperative

Homeowner/Renters Ins.

How long have you lived at this address? *

How long have you lived in Washington? *

Applicant A - Do you have a current Washington State drivers license? *

Yes

Applicant A - Insurance Company *

Applicant A - Drivers license # *

Applicant B - Do you have a current Washington State drivers license? *

Yes

Applicant B - Insurance Company *

Applicant B - Drivers license # *

Do you have renters/homeowner insurance? *

Yes

Company and Policy # *

Can you provide a private room/space for a youth? *

Yes

Are you planning on moving within the next year? *

Yes

References *

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

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Relationship *

Years known *

Reference 2 - Name *

Reference 2 - Name

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Relationship *

Years known *

Members of Household - 1 *

Members of Household - 1

(Include roommates, relatives, children and others in home)

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Gender Identity *

Relationship *

Members of Household - 2 *

Members of Household - 2

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Gender Identity

Relationship *

Members of Household - 3 *

Date of Birth *

Date of Birth

YYYY

Gender Identity *

Relationship *

Members of Household - 4 *

Date of Birth *

Date of Birth

YYYY

Gender Identity *

Relationship *

Do they have concerns? *

Yes

If yes, please list concerns *

Please list number/type of pets in your household *

Briefly, describe your interest in wanting to host a young person in your home *

Please describe the age, gender, and other characteristics of a young person you would wish to host *

Please write about your strengths, skills and any other relevant information that you would like to share *

Have you ever been a convicted of a crime? *

This doesn’t rule you out of becoming a host home volunteer

Yes

If yes, please describe *

Have you ever been a licensed as a foster parent? *

This is not a requirement for the Rotary Host Home Program.

Yes

If yes, with what agency? *

I hereby authorize Youth Empowerment Strategies and the Rotary Host Home Program to perform a criminal background check on persons listed on this application. I hereby certify that the facts contained within the Rotary Host Home Program Application are true and complete to the best of my knowledge. I understand that completion of this application and process is not a guarantee of becoming a host home volunteer or having a youth placed in my home. *

Electronic Signature Applicant A *

Electronic Signature Applicant A

First Name

Last Name

Date *

Date

YYYY

Electronic Signature Applicant B *

Date *

Date

YYYY

Thank you!