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
MM
DD
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
MM
DD
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
(###)
###
####
How long have you lived at this address? *
How long have you lived in Washington? *
Applicant A - Insurance Company *
Applicant A - Drivers license # *
Applicant B - Insurance Company *
Applicant B - Drivers license # *
Company and Policy # *
Reference 1 - Name *
Reference 1 - Name
First Name
Last Name
Date of Birth *
Date of Birth
MM
DD
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
MM
DD
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
MM
DD
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
MM
DD
YYYY
Gender Identity
Relationship *
Members of Household - 3 *
Date of Birth *
Date of Birth
MM
DD
YYYY
Gender Identity *
Relationship *
Members of Household - 4 *
Date of Birth *
Date of Birth
MM
DD
YYYY
Gender Identity *
Relationship *
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 *
If yes, please describe *
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
MM
DD
YYYY
Electronic Signature Applicant B *
Date *
Date
MM
DD
YYYY