Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Are you married? *

Yes

No

Do any children reside in the household? *

Yes

No

Are you a member of Emmanuel Church? *

Yes

No

How long have you attended Emmanuel Church? *

1 year or less

2-4 years

5 years or more

Reference 1 Name *

First Name

Last Name

How long have you known Reference 1? *

1 year or less

2-5 years

6-10 years

11 years or more

Reference 1 Phone Number *

(###)

###

####

Reference 2 Name *

First Name

Last Name

How long have you known Reference 2? *

1 year or less

2-5 years

6-10 years

11 years or more

Reference 2 Phone Number *

(###)

###

####

I am a Christian and believe all of the statements above to be true. *

Yes

No

I believe that I meet the expectations and qualifications for serving as a member of the Emmanuel Host Home team. *

Yes, I agree.

I am unsure and would like to discuss questions with a pastor.

I agree to adhere to the expectations and qualifications of an Emmanuel Church Host Home. *

Yes, I agree.

I am unsure and would like to discuss questions with a pastor.

Do you give consent to Emmanuel Church to conduct a background check? *

A background check may include, but is not limited to, the following: criminal records, social media, and employment history.

Yes

No

Do you give consent to Emmanuel Church to conduct a home visitation? *

A home visitation is conducted to ensure that residents will be provided with a safe, quality living environment during their time at Emmanuel.

Yes

No