Host Family Agreement

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Name of Applicant*First, Middle Initial, Last

Date of Birth*

Spouse/Partner Name*

Mailing Address*

Physical Address*

Home Phone Number

Cell Phone Number*

Work Phone Number

Email*

Occupation(s)*

WNCC Affiliation (if any)

Please provide the following information about other individuals in the household:*Surname, First Name, Date of Birth, Gender, Relation to Volunteer

Languages Spoken*

Request for a specific student:

Emergency Contact
In case of an emergency, whom should we notify?

Emergency Contact*Name, Relationship, Telephone Number

Background:

Have you or any other household members ever been convicted of a felony or misdemeanor or entered a plea of guilty, nolo contendere / no-contest, or similar plea that exposed you, or relevant household member, to the possibility of punishment? If so, please describe, including dates, jurisdiction, and penalty.
Have you, or any household members, ever been adjudicated or otherwise entered a plea of admit, no contest, or similar plea in a juvenile court proceeding that relates in any way to violence, sexual misconduct or child neglect or abuse. If so, please describe, including dates, jurisdiction, and any disposition entered by the Court.
At the present time, is there any criminal charge or juvenile court case pending against you or any member of your household that relates in any way to violence, sexual misconduct, or child neglect or abuse? If so, please describe, including charge, jurisdiction, and date of arrest, charge or indictment.

Background Anwsers*

I certify that the information provided on this Application is true and understand that it is subject to independent verification. My failure to provide truthful answers will result in consequences up to and including refusal to consider the application or immediate termination as a volunteer. If selected, I will comply with all requirements of WNCC volunteers and the Host Family Volunteer Program and acknowledge that Western Nebraska Community College may, at its discretion, terminate my participation in the program at any time.

I understand that work with minors and/or other students in the Host Family Volunteer Program is contingent upon consent to and successful completion of any required background check, which includes a criminal background check and a sex offender registry check. A criminal conviction will not automatically disqualify an applicant from volunteering at WNCC and background check information will be used in a confidential, non-discriminatory manner consistent with state and federal law.

Volunteer Agreement Digital Signature*I acknowledge that by writing my name I am agreeing.

In signing this release, I acknowledge and represent that I have read the Waiver & Release Agreement, understand and agree to be bound by it, and sign it voluntarily; I am at least nineteen (19) years of age and fully competent.

Waiver and Release Agreement Digital Signature(s)*I acknowledge that by writing my name I am agreeing.