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Winter Miracles® Host Family Report 2011 Week 1

Please complete a separate form for each child that you are hosting.



	Name* First Name Last Name
	Address City State Zip Code
	Phone
	Email
	Are you a single parent or a couple? Single Couple
	Number of other children in the family not counting the Winter Miracles Child.
	Winter Miracles Child Full Name: First Name Last Name
	Child's Birth Date:
	Child's Sex: Male Female
	City of the Child's Orphanage:
	Date Child Entered Your Home:
	1. How did you learn about the Winter Miracles Program and what made you decide to host in this program?
	2. Please describe your first reaction when you saw the child:


	A Reminder: Next week we need you to send us photos.


	A copy of this completed questionnaire will be sent to Kidsave. You will also receive a confirmation copy by return E-mail for your records.