Kidz Pods Host Family Application

Kidz Pods Host Family Application

Complete this application using the extracted PDF structure and questions. All phone fields must use the Phone Number field type.
Applicant Information
Primary Applicant Full Name

First NameLast Name
Co-applicant Full Name

First NameLast Name
Best Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about Kidz Pods?

Other
If referred, by whom?
Home Eligibility and Children
Is your home located in a gated community?
Property access explanation
Number of children in the household
Child 1 name

First NameLast Name
Child 1 age
Child 1 grade
Child 2 name

First NameLast Name
Child 2 age
Child 2 grade
Pod selection
Are any children currently enrolled or planning to enroll?
Is your home education student registered with an organization?
Organization name
Pod Space Details
Type of pod space

Other
Other pod space type details
Square footage
Separate entrance
Climate-controlled
Bathroom access

Other
Natural light
Stairs involved
Describe stairs, if any
Outdoor area access
Describe outdoor area, if any
Parking available
Furniture or equipment required
Quiet area available
Potential disturbances nearby
Describe disturbances, if any
Safety and Home Environment
Body of water on or near property?
If yes, describe the body of water
Are firearms present in the home?
If yes, describe firearm storage and access
Smoke detectors installed?
Carbon monoxide detectors installed?
Fire extinguisher available?
First aid kit available?
Nearest ER or urgent care facility name
Nearest ER or urgent care facility address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Distance to nearest ER or urgent care (miles)
Do you have any pest issues?
If yes, describe the pests
Do you have any mold or mildew issues?
If yes, describe the mold or mildew
How often is the home cleaned?
Has the HVAC system been serviced recently?
If yes, how often is the HVAC system serviced?
Pets and Household Conditions
Do you have any pets in the home?
Pet 1: Type and number
Pet 2: Type and number
Where are pets kept?
How are pets secured?
Is smoking allowed in the home?
Are nut products used or present in the home?
Is latex used or present in the home?
If yes, please describe latex use or exposure
Which cleaning products are used in the home?

Other
Are fragrance products used in the home?
If yes, please describe fragrance product use
Are pesticides used in or around the home?
If yes, please describe pesticide use
Other allergens in the home
Household Adults and Background Information
Adult 1 Name

First NameMiddle NameLast Name
Adult 2 Name

First NameMiddle NameLast Name
Adult 3 Name

First NameMiddle NameLast Name
Adult 4 Name

First NameMiddle NameLast Name
Background Check Consent
Education or Childcare Profession
If yes, please describe your education or childcare profession
CPR/First Aid Certified
If yes, please describe your CPR/First Aid certification
Medical conditions or concerns
Faith Motivation and Availability
Do you agree with the Christ-centered mission of Kidz Pods?
Do you regularly attend church?
Church name
Church city
What motivates you to host a Kidz Pods child?
What values or beliefs guide your home and family life?
Additional faith, family, or hosting information
Are you available to host for the full year?
Do you have any unavailable dates or periods?
Please describe any unavailable dates or periods
Do you have active homeowner's or renter's insurance?
Insurance provider and policy details
Do you use non-toxic and fragrance-free household products?
Are you open to hosting multiple pods?
Acknowledgements and Signatures
Primary Applicant Signature
Printed Name

First NameMiddle NameLast Name
Date Signed

MonthDayYear
Date
Co-Applicant Signature
Co-Applicant Printed Name

First NameMiddle NameLast Name
Co-Applicant Date Signed

MonthDayYear
Date
Should be Empty:

Kidz Pods Host Family Application

Applicant Information

Home Eligibility and Children

Pod Space Details

Safety and Home Environment

Pets and Household Conditions

Household Adults and Background Information

Faith Motivation and Availability

Acknowledgements and Signatures