Petition to Host – Summer

Last Name (App. 1):

First Name (App. 1):

Age (App. 1):

Occupation (App. 1)

Employer Name (App. 1)

Last Name (App. 2):

First Name (App. 2):

Age (App. 2):

Occupation (App. 2):

Employer Name (App. 2)

Home Address:

City:

State:

Zip:

Phone

Marital Status:

Single     Married

Other children at home and ages:

Contact Information:

Home:

phone:

fax:

e-mail:

cell/mobile phone:

Office
(Applicant 1):

phone:

fax:

Office
(Applicant 2):

phone:

fax:

Homestudy Status:

Do you have an approved homestudy?

Yes  No

If so, date completed:

If no, have you begun your homestudy?

Yes  No

If yes, estimated completion date:

Please note: All potential parents interested in meeting kids need to contact agencies. Most agencies will require a local police child abuse clearance or other safety check prior to arranging meetings.

Hosting Preferences:

Is this petition for:

Host for summer 2006
Anytime during the year
For 2007 or beyond

Number of children you wish to host:

Because of the nature of life in an orphanage, older children from Eastern European institutions will have delays in development and may have other medical or psychological issues that will require attention and care, both emotionally and financially. Some of these issues may be apparent during the six-week visit while others may not be apparent during the visit. Kidsave makes every effort to screen these children but each family must carefully and individually weigh the issues. Kidsave cannot assure any prospective parent or even Summer Miracles participant that the child will be problem-free.

I am interested in hosting a Summer Miracles child and am aware that all of the children will have issues that will need time and attention, both short and long term. 

I will also accept a child with a known...

medical problem
psychological problem

Please indicate the age range and gender of the child you wish to host, if you have specific preferences. (CANNOT GUARANTEE)

Preferences:            Male     Female     Either        

7-9 years old:                                

10-12 years old:                            

13 and older:                                 

No age preference:                      

Other desires or comments regarding a child:

Payment:

You will be directed to our secure server to make your $35 payment on-line after you submit this form.