Host Family Application

Deadline for 2012 Host Family Applications is April 15, 2012.

You can submit online, or print out and mail to:

Gail Tatsuda
116 Yale Ct.
Glenview, IL 60026

Questions? Contact Host Family Coordinator Gail Tatsuda, 847-707-3717.

Host Family Information:

Last Name(s) *

First Name(s) *

Mailing Address *

City *

State *

Zip Code *

Home phone *

Cell phone(s)

Email address(es) *

Religion(s) practiced in household: *

Language(s) spoken in household: *

Place(s) of worship: *

Residents Full Names *

Please list the names and ages of all residents in the household. Please indicate gender (M or F) and indicate all adults (anyone 21 or older) with an (A).

Please list any pets in household (including birds, fish, reptiles, etc.):

Are you willing to host teens of another religion? *

Yes

If so, which religion: *

Christian

Jewish

Muslim

Any

Does anyone in your home smoke cigarettes, cigars or pipes? *

Yes

Would you allow your visitor to smoke at your home:

Inside *

Yes

Outside *

Yes

Are you willing to host a teen with dietary restrictions (guidelines would be provided)?

Would you prefer to host a boy, girl, or either? *

Boy

Girl

Either

How many teens would you be willing to host? *

Can you offer your visitor a private bedroom? *

Yes

During the program, who would typically be home during the day? *

During the program, who would typically be home during the evening? *

Would someone from your home be available to drive your visitor to and from program activities during the day? *

Yes

Would someone from your home be available to drive your visitor to and from program activities during the evening? *

Yes

References

If this is your first time applying to be a host family, please list three references we can contact:

Reference 1

Reference name

Mailing address

City

State

Zip code

Email address

Phone

How do you know this person?

Reference 2

Reference name

Mailing address

City

State

Zip code

Email address

Phone

How do you know this person?

Reference 3

Reference name

Mailing address

City

State

Zip code

Email address

Phone

How do you know this person?

Have you been a host family before? *

Yes

If so, please explain:

What do you hope to gain from hosting with Hands of Peace? *

Additional required forms

For each adult in the family, the following two forms must also be printed, filled out, and sent in hard copy form to Gail Tatsuda (see her address at top of this form).

Click here for “Authorization to release information form”

Click here for “Applicant disclosure affidavit”

As part of the application process, we will also contact references, conduct home visits and interviews, and conduct background checks (including local, state, federal and driving record) on each adult in the household.

If you have questions, call Gail Tatsuda at (847) 707-3717

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Host Family Application