Host Family Volunteer Program Application

Host Family Volunteer Program Application

The LCCC Host Family Volunteer Program is designed to connect LCCC students to members of the community. It is not a live-in program, but rather an opportunity for students to engage with people in the community as well as to have a resource for questions and support.

After you have completed the application to serve as a Host Family, we will reach out regarding the next steps.

Applicant Last Name*

Applicant First Name*

Spouse/Partner Last Name

Spouse/Partner First Name

Mailing Address*

Physical Address*

Email*

Cell Phone*

Phone

Applicant Occupation*

Work Phone

Phone

Spouse/Partner Occupation

Household Members

List the names and ages of any children and other people who live in the home.

Pets

Please list name, breed, and age of all pets in the home.

Language(s)

Please list all languages spoken in the home.

Emergency Contact*

Please list the name, relationship, and phone number for the emergency contact.

LCCC Affiliation (if any)

Comments/Requests

Background Information

All adults in the household must answer the following questions.

Applicant Background question 1:*

Have you ever been convicted of a felony or misdemeanor or entered a plea of guilty, nolo contendere / no-contest, or similar plea that exposed you to the possibility of punishment?

YES

Applicant Background Follow Up Q1:

If YES, please describe, including dates, jurisdiction, and penalty.

Applicant Background question 2:*

Have you 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.

YES

Applicant Background Follow-up Q2:

If YES, please describe, including dates, jurisdiction, and any disposition entered by the Court.

Applicant Background question 3:*

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?

YES

Applicant Background Follow-up Q3:

If YES, please describe, including charge, jurisdiction, and date of arrest, charge or indictment.

Spouse/Partner Background Question 1:

Have you ever been convicted of a felony or misdemeanor or entered a plea of guilty, nolo contendere / no-contest, or similar plea that exposed you to the possibility of punishment?

YES

Spouse/Partner Background Follow-up Q1:

If YES, please describe, including dates, jurisdiction, and penalty.

Spouse/Partner Background Question 2:

YES

Spouse/Partner Background Follow-up Q2:

If YES, please describe, including dates, jurisdiction, and any disposition entered by the Court.

Spouse/Partner Background Question 3:

YES

Spouse/Partner Background Follow-up Q3:

If YES, please describe, including charge, jurisdiction, and date of arrest, charge or indictment.

Is there another adult in the home?

YES

Additional Adult Background Question 1:

Have you ever been convicted of a felony or misdemeanor or entered a plea of guilty, nolo contendere / no-contest, or similar plea that exposed you to the possibility of punishment?

YES

Additional Adult Background Follow-up Q1:

If YES, please describe, including dates, jurisdiction, and penalty.

Additional Adult Background Question 2:

YES

Additional Adult Background Follow-up Q2:

If YES, please describe, including dates, jurisdiction, and any disposition entered by the Court.

Additional Adult Background Question 3:

YES

Additional Adult Background Follow-up Q3:

If YES, please describe, including charge, jurisdiction, and date of arrest, charge or indictment.

Any additional adults in the home?

YES

Contact Program Administrator

Please contact Amanda Ramsey if there are more than three adults in your home.

Host Family Attestation*

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 LCCC volunteers and the Host Family Volunteer Program and acknowledge that Laramie County 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 LCCC and background check information will be used in a confidential, non-discriminatory manner consistent with state and federal law.

Signature*

Type your name below to sign the form.

Send me a copy of my responses

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