HOST FAMILY APPLICATION Please type or print legibly.

Transcription

1 HOST FAMILY APPLICATION Please type or print legibly THIS SECTION FOR OFFICE USE ONLY ASSIGNED STUDENT:(S) FAMILY APPROVED: () YES () NO HOST FAMILY PROFILE Father s full name: Age: Date of Birth: / / Home address: City: State: Zip: Home phone: Cell phone: Level of education: Place of employment and occupation: Business address: City State: Zip: Phone: ( ) B) Mother s full name: Age: Date of Birth: / / Home address: City: State: Zip: Home phone: Cell phone: Level of education: Place of employment and occupation: Business address: City State: Zip: Phone: ( )

2 List all children living in your home by age and sex. Please list full name of all other persons living in your home and their age/relationship to you. Please list hobbies or any special interest of the adults in your home: Please list hobbies or any special interest of children in your home. Does your family belong to any clubs or organizations?

3 Does any member of your family have a psychological or physical disability? ( ) No ( ) Yes, please explain. Please list any health, allergy, or dietary needs or conditions in your family. Do you have pets in your home? If so, which pets? Does anyone in your family play a musical instrument?

4 EMERGENCY CONTACTS Please provide the Dodge City Community Host Family Program with an emergency contact outside your home: Name: Relationship Address: Phone: ( ) City: State: Zip: REFERENCES Please provide the Dodge City Community College Host program with information for the three reference sections listed below so that we may contact them. Your application cannot be finalized without these three contacts. Information provided on the reference forms will remain confidential. A) PERSONAL (not a relative) Name: Years acquainted: Address: Home phone Cell phone: B) PROFESSIONAL Name: Title: Years acquainted: Address: Home phone: Cell phone: C) Clergy Name: Years acquainted Address: Home phone: Cell phone:

5 LIMITED NUMBER OF STUDENTS TO HOST AND RELATED INFORMATION The DCCC Host program has a limit of two students per family. Would you like to host one or two students? Please indicate, with a check mark, if you d prefer to host Young ladies or young men. 1) This program does not allow you to add any student(s) to your assigned and limited number of two, under any circumstance. 2) Adding students to your assigned and limited number, without the prior knowledge of the host program committee at DC3, will immediately void your participation in the program and your host student(s) will be removed. Please clearly indicate your reasons for wanting to participate in the host program through DCCC. The Host Family program, through DCCC, is a non-live in situation. Students are never, for any reason, to spend the night at your home. Students are never to travel with you out of town when you have plans of spending the night. You are never to give money to your students or their families in any form. (Cash, gifts, restaurant meals). They are not your financial responsibility. If selected, do you agree to follow all guidelines as set forth through DCCC, as well as the NJCAA and KJCCC?

6 Please carefully read the KJCCC and NJCAA guideline. Sign and date below. You should be aware that the NJCAA PROHIBITS the following:! Permitting an athlete to receive assistance, in cash or in kind, which is not administered by the institution, or which does not fall within the permissible limits of a grant-in-aid (tuition & books)! Permitting a member of a student-athlete s family to receive assistance, in cash or in kind.! Purchasing meals at restaurants for student-athletes! Contributing to the payment of registration fees for prospects to attend sports camps! Mailing anything of benefit to a prospective student-athlete except personal letters! Permitting athletes to engage in employment for which they receive greater compensation, or in which they are not required to work as hard as others in similar employment or which is otherwise not legitimate employment! Paying transportation costs for prospects or their friends and relatives to visit Dodge City Community College! Permitting a prospective student-athlete to be solicited to attend their institution by the promise of gift or any aid or inducement other than that of a Grant-in-Aid permitted by NJCAA and KJCCC rules! Contacting student-athletes enrolled at other two-year institutions to explore the possibilities for transferring to Dodge City Community College! Permitting or arranging for excessive entertainment of a prospect on campus or elsewhere during the prospects official visit! Providing a student-athlete with a discount, payment plan or credit on a service! Providing a student-athlete with professional services without charge or at a reduced cost! Permitting the institution or a representative of its athletic interests to provide an automobile for use by a prospect or the prospect s student host during the prospect s official visit.! Permitting any outside organization, agency or group of individuals to utilize, administer or expend funds for recruiting prospects, including the transportation and entertainment of, and the giving of gifts or services to, prospects or their relatives or friends! Allowing a student-athlete to use a phone or credit card without charge or at a reduced rate! Making available to student-athletes services (movie tickets, dinners, use of car, etc.) from commercial agencies without charge or at a reduced rate! Providing a student-athlete with extra benefits or services including but not limited to loaning money or guaranteeing a bond, use of an automobile, signing or cosigning a note with an outside agency to arrange a loan Print Family Name: Date First adult signature and date of birth: Second adult signature and date of birth:

7 Please indicate who completed this application. Are there any final comments or questions? Dodge City Community College Host Program will retain this document, in its original form. NOTICE OF NON-DISCRIMINATION Dodge City Community College does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities. The following persons have been designated to handle inquiries regarding the non-discrimination policies: Dean of Student Services, 2501 N. 14th Avenue, Dodge City, Kansas 67801, (620) or Director of Human Resources, 2501 N. 14th Avenue, Dodge City, Kansas 67801, (620) ,