Connecting people and fostering independence through innovative and affordable housing, because everyone needs a place to call home.

Youth Host Home Provider Application
Today's date*

MonthDayYear
Have you ever applied to be a host home provider with Shared Housing Services or Associated Ministries before?*
If yes, when?

MonthDayYear
Personal Information
Name*

First and Middle NameLast Name
Preferred Gender Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone Number*
Home Number
E-mail*
example@example.com
Date of birth:*

MonthDayYear
How would you describe your race?
Emergency contact:*
Emergency contact phone number:*
Relationship:*
Names in household:

Please list all members of household, other than yourself.
First household member:
Name

First NameLast Name
Relationship to applicant?
Gender
Date of birth

MonthDayYear
Second household member:
Name

First NameLast Name
Relationship to applicant
Gender
Date of birth

MonthDayYear
Third household member:
Name

First NameLast Name
Relationship to applicant?
Gender
Date of birth

MonthDayYear
Fourth household member:
Name

First NameLast Name
Relationship to applicant?
Gender
Date of birth

MonthDayYear
Employment/Education
Are you currently employed?*
Present or most recent employer?*
Position or title*
Length of employment?
Are you a student?*
Name of school?
Program of study?
Estimated graduation date?

MonthDayYear
Income
Source of income (check all that apply):

Wages/salarySocial SecurityPensionRetirementSavingsS.S.I/S.S.DUnemployment
Annual household income:

$0-$30,000$30,000-$50,000$50,000-$80,000$80,000-$100,000$100,000+
Health
Any past drug use?*
Last used?
Have you been diagnosed with a mental illness?*
If yes, please explain:
Criminal History
Have you been involved with CPS?*
If yes, please explain:
Have you ever been detained, arrested, or convicted of a crime?*
When?

MonthDayYear
Do you have active warrants?*
If you answered yes to any of the above questions, please explain:
Associated Ministries works with individuals and families from a variety of backgrounds and cultures. Are you comfortable sharing a home with someone who has a different background or culture than you with regards to...
Race/Ethnicity?*
Sexual orientation?*
Gender?*
Religion?*
If you have checked no on any of the options above, please tell us more about what you prefer.
Matching Criteria

Please answer all the questions below so that we can better match your needs.
Do you smoke?
Do you use Marijuana?
Do you drink?
What would be the smoking rules (tobacco and/or marijuana) in your home? Please describe if smoking is allowed, and if so, where:
Do you have pets?
If yes, please tell us about your pets:
Will you allow the youth/young adult to bring a pet?
If you selected "yes" or "depends," please explain:
Concerns and/or questions you may have about home sharing?
References

Please provide two references that we may contact (who are not related to you).
Reference 1
Reference Name*

First NameLast Name
Phone Number*
Relationship?*
Reference 2
Reference Name*

First NameLast Name
Phone Number*
Relationship?*
Criminal History Policy
As a social service agency, we value safety and well-being of our clients, employees, and volunteers. It is therefore the policy of Associated Ministries (AM) to carefully screen all applicants for any criminal charges, arrests, convictions, and warrants. Applicants are screened through Checkr multistate background check.

Based on the information received by Checkr through a completed background check, it is our policy not to refer any applicant to the Host Home Program who has been charged, arrested, or convicted of the following crimes within the last ten years: felonies, thefts, domestic violence, crimes of child or elder abuse, and any actions involving destruction of property or physical violence toward persons. Additionally, any active warrants will also serve as grounds for denial of participation from the program, regardless of how old the warrant is. Applicants must resolve all active warrants and go through the appeal process in order to be reconsidered for participation. Clients who possess a criminal history that features sexual crimes, murder, or voluntary manslaughter within their lifetime will be automatically disqualified and unable to request an appeal.

Upon receipt of an adverse criminal history report, the applicant will be sent a letter denying their application due to relevant criminal history. It will state which crimes fall under the policy criteria as well as procedures to follow if the client wishes to seek review/reconsideration through the appeal process. The client is allowed a period of two months to schedule a criminal appeal appointment. If the client fails to do so within this given timeframe, they will not be able to reapply for entrance into the program for the next two years.

Policy on nondiscrimination: All services offered by AM are provided in a manner which is free from discrimination on the basis of race, color, religion, sex, sexual orientation (gender identity/expression), national origin, age, handicap, and familial status.
Acknowledgment*

I certify that I have read the Criminal History Policy and that I understand and agree to the above information.
E-signature (participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner))

First NameLast Name
Date

MonthDayYear
Associated Ministries Release of Information (general)
I hereby authorize the Associated Ministries (AM) staff to send information to and discuss my personal circumstances with AM coordinators and staff of other agencies.

It is understood that any interchange of information made between staff and coordinators of AM and other agencies will be used only for purposes of attempting to determine appropriate services on my and my family's behalf.

I also authorize AM staff to provide information supplied by myself and information on any arrest and/or criminal convictions obtained by AM to potential home sharers in the process of attempting to bring about a home sharing arrangement on my behalf.
Acknowledgment *

I agree to the release of information as stated in the Associated MInistries Release of Information form.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/partner)

First NameLast Name
Date

MonthDayYear
Program Exit Guidelines
Associated Ministries (AM) is a non-discriminatory, equal opportunity non-profit agency. We strive to serve Pierce County regardless of gender, age, race, religion, sexual preference (gender identity/expression), or socio-economic status. As part of the program, AM requires everyone to provide copies of photo identification and proof of income.

Below is a list of reasons a participant may no longer receive services and be exited from the program:
1. Falsifying information
2. Disrespectful to staff in person, on the phone, or in writing
3. Disrespectful behavior toward another home sharer or home provider
4. Damage done to AM property, the property of a home provider, or the property of a home seeker
5. Inappropriate behavior or boundaries toward staff or a program participant
6. Crimes or illegal actvity committed while in the program
7. Non-compliance with substance abuse or mental health treatment
8. Lack of contact by a non-matched program participiant by phone, email, and mail after 2 months
9. Failure to comply with services or rent contractually agreed upon by the home seeker and home provider
10. Failure to comply with Washington State landloard/tenant laws
11. If the home becomes uninhabitable or not fit for home sharing
Staff exercises their right to exit anyone from the program if they fall into one of the above listed categories. The list is not comprehensive and someone may be asked to leave for another reason. In addition, staff may use discretion at anytime and allow a participant to stay in the program based on the nature of the offense.
Acknowledgement*

I have read and understand the above Program Exit Guidelines. I acknowledge that anything listed above may result in dismissal from the program, and that I am responsible for my own behavior toward staff, volunteers, and program participants.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Agreement of Non-liability
I understand that the staff of Associated Ministries (AM) will use their facilities to
bring together those who have available housing (homeowner's) with those who
express a desire for housing (home seekers).

I, as a home owner, understand that AM is not the agent of either party, but acts only as a facilitator, to provide the opportunity for the parties involved to come together and work out an acceptable housing agreement.

I, as the home owner, am not relying entirely on AM to screen home seekers. I understand that AM completes and signs AM program intake forms with the home seeker, runs a background check, and is present at move-in when forms are signed by the home seeker and myself. All credit checks, references and all other background information would need to be obtained and/or confirmed by myself.

Any disputes between the homeowner and home seeker which may arise shall not involve the staff of AM, either individually or as a group, except where I request assistance with conflict mediation. I, as the home owner, understand that neither AM nor any AM staff will be responsible nor will I hold them responsible for any claims, damages, or other consequences which may arise from any home sharing arrangement. I further understand that, should I have any questions about my legal rights and the laws of the State of Washington regarding this agreement, I should consult my own attorney.
Acknowledgement*

I have read and understand the above Agreement of Non-liability.
E-signature (Participant)

First NameLast Name
Date

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Photo/Video/Audio Media Release
By acknowledging this release, I give Associated Ministries (AM) permission to use (1) my picture-including photos, videos, and electronic images, and (2) my voice-including sound and video recordings.

This gives Associated Ministries' employees and partners permission to publish, reproduce, and distribute my name, image, and voice in all languages, media, formats, and markets now known or created in the future, including, but not limited to: Conferences and fundraising events, inclusion in newsletters, press releases, blogs, social media, donation requests, news coverage, advertising via television and internet, and website content.

I agree to hold harmless AM and its staff and partners for any alteration of my image or voice, intentional or unintentional, which may arise in the production process.

I waive the right to receive payment for AM use of any of the material described above, and to inspect or approve finished photos, audio, or video.
Minors:

I certify that I am the legal parent/guardian of the following minor(s), under the age of 18, to whom this Photo/Video/Audio Media Release shall apply
Name 1

First NameLast Name
Name 2

First NameLast Name
E-signature (Parent/Guardian)

First NameLast Name
Date*

MonthDayYear
Acknowledgement*

I am 18 years of age or older, have read the Photo/Video/Audio Media Release and understand its contents.Client(s) decline photo release*
* Declining this release has no effect on distribution of services.
E-signature (Participant)*

First NameLast Name
Date*

MonthDayYear
E-signature (Spouse/Partner)

First NameLast Name
Date

MonthDayYear
Should be Empty:

Youth Host Home Provider Application

Personal Information

Names in household:

First household member:

Second household member:

Third household member:

Fourth household member:

Employment/Education

Income

Health

Criminal History

Matching Criteria

References

Criminal History Policy

Associated Ministries Release of Information (general)

Program Exit Guidelines

Agreement of Non-liability

Photo/Video/Audio Media Release