Name of Family: Address: City: State: Zip: Home Work Phone: Cell: HOME/RESIDENCE INFORMATION Total Capacity Requested: Body of Water on Property: N/A Preferred Gender of Children Pool Hot Tub Placed: Other: Male Female No Preference Preferred Age Range of Children Physical Environment Completed Placed: (Home and Grounds): Age: to Age: Yes No APPLICANT INFORMATION APPLICANT #1 APPLICANT #2 Maiden Name/Alias/AKA: Maiden Date of Date of Birth: Social Security #: Social Security #: Place of Birth: of Birth: Ethnicity: Ethnicity: Citizenship Status: Citizenship Status: Male Female Male Female Religion: Religion: Education: Education: Language(s): Language(s): Occupation: Occupation: Employer: Employer: Annual Gross Income: Annual Gross Income: Tribal Affiliation: Tribal Affiliation: Date of Health Screening: Date of Health Screening: TB Test Results: TB Test Results:
Name of Family: Address: City: State: Zip: Home Work Phone: Cell: HOME/RESIDENCE INFORMATION Total Capacity Requested: Body of Water on Property: N/A Pool Hot Tub Other: Preferred Gender of Children Placed: Male Female No Preference Preferred Age Range of Children Placed: Age: to Age: Physical Environment Completed (Home and Grounds): Yes No APPLICANT INFORMATION APPLICANT #1 APPLICANT #2 Maiden Name/Alias/AKA: Maiden Date of Date of Birth: Social Security #: Social Security #: Place of Birth: of Birth: Ethnicity: Ethnicity: Citizenship Status: Citizenship Status: Male Female Male Female Religion: Religion: Education: Education: Language(s): Language(s): Occupation: Occupation: Employer: Employer: Annual Gross Income: Annual Gross Income: Tribal Affiliation: Tribal Affiliation: Date of Health Screening: Date of Health Screening: TB Test Results: TB Test Results: