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Summer Miracles® Hosting Inquiry Form

Please complete this form if you are interested in hosting a Summer Miracles child this summer. You will receive an email confirming receipt of your petition.

*Applicant 1 Full name:

Applicant 2 Full name:

*Home Address:

*City:

*State:

*Zip:

*Home Phone:

Home Fax:

Partnership Status:
Single Cohabit Married Separated Divorced

If married, what date?

(mm/dd/yyyy)

Applicant 1

Age:

Birth date:

(mm/dd/yyyy)

Are you a U.S. Citizen?
Yes No

If not, what is your citizenship status?

Occupation (please describe):

Employer:

Business Address:

City:

State:

Zip:

Office Phone:

Office Fax:

Cell Phone:

E-mail:

Applicant 2

Age:

Birth date:

(mm/dd/yyyy)

Are you a U.S. Citizen?
Yes No

If not, what is your citizenship status?

Occupation (please describe):

Employer:

Business Address:

City:

State:

Zip:

Office Phone:

Office Fax:

Cell Phone:

E-mail:

Children Already in the Household:

Full Name Birth Date M/F Bio/Adoppted Country/Date

Please check if either applicant has history of the following:
Criminal Activity
Psychiatric Hospitalization
Substance Abuse/DUI
Domestic Violence
Disrupted Adoption

How Did You Find About Kidsave Summer Miracles?

Paperwork Status

1. Do you have an approved homestudy? (If no, skip to question 3)
Yes No

1a. If so, date completed :

(mm/dd/yy)

1b. Number of children approved for:
1 2 3 4 5 6

2. Homestudy agency:

Social Worker Name:

Agency Phone:

Agency Address:

3. If no, have you begun a homestudy?
Yes No

If yes, when was it started:

(mm/dd/yy)

4. Do you have I600A approval? (If no, skip to question 5)
Yes No

4a. Date submitted:

(mm/dd/yy)

4b. Number of children approved for:
1 2 3 4 5 6

4c. Date Approved:

(mm/dd/yy)

5. Do you have a foster care license?
Yes No

6. Have you ever been denied approval by a child placement agency?
Yes No

Hosting Child Preferences

1. In what year would you like to host? (yyyy)

2. How many children are you willing to host?
1 (Single child) Sibling set of 2 Sibling set of 3 Sibling set of 4

3. Please indicate the age range and gender of child you wish to host.
8-9 years old 9-11 years old over 11 years old No age preference

3a. Please indicate the age range and gender of child you wish to host.
Male Female Either

Because of the nature of life in an orphanage, older children from institutions will have delays in development and may have other medical or psychological issues that will require attention and care, both emotionally and financially.

I am interested in hosting a child in the Summer Miracles program and am aware that all of the children will have issues that will need time and attention.

I will also accept a child with a known
medical problem
development problem
psychological problem

Host parent applicants must pay a $275 non-refundable application fee which is used to help cover some of the costs of bringing the children to the US. By clicking Submit Form, you will be brought to a secure site for on-line payment of the host application fee.