APPLICATION
YEAR SEASON TODAY’s DATE:
PAPERWORK HELP:
LATVIA: (231) 638-0847UKRAINE: , (702) 686-3684 KYRGYZSTAN:, (216) 513-5855
PURPOSE OF APPLICATION:
All information is kept strictly confidential and used only for the purpose of assessing your hosting qualifications.
Traditional-New Host Family (4-6 weeks) Home Safety Visit GA, CO, FL, KY, WY, TX Back-Up Host Family
Traditional-Re-Host Family (4-6 weeks)Extended-Re-Host Family (8-11 weeks, Summer Only) Addt’l fee
HOST FAMILY INFORMATION:
(Previous host families only: List changes in your family or home since last host experience.)
ADDRESS: (Used as your hosting location for airport arrival selection and primary contact info.)
Street Address:
City: State: Zip:
Home Phone: Cell Phone:
Primary Email: Secondary Email
HOST FATHER:
Last Name: Middle Name: First Name: Other Names Known By:
Age: Date of Birth: Place of Birth: Race: Citizenship:
Hair Color: Weight: Social Security #: Driver’s License Number:
Education: Occupation: Employer:
Work Address: Work Phone:
Work Email: Work Fax:
Length of Employment: Annual Salary: Additional Income:
Date/Place of Current Marriage: Number of Previous Marriages:
Previous Marriage Dates Divorce Dates:
HOST MOTHER:(Host mother’s first and last name will be the PRIMARY ACCOUNT HOLDER’s name in our data base.)
Last Name: Middle Name: First Name: Maiden Name:
Age: Date of Birth: Place of Birth: Race: Citizenship:
Hair Color: Weight: Social Security #: Driver’s License Number:
Education: Occupation: Employer:
Work Address: Work Phone:
Work Email: Work Fax:
Length of Employment: Annual Salary: Additional Income:
Date/Place of Current Marriage: Number of Previous Marriages:
Previous Marriage Dates Divorce Dates:
CHILDREN IN YOUR HOME:
Name: DOB: Age:Sex:Living With You? Adopted/Biological?
Name: DOB: Age:Sex:Living With You? Adopted/Biological?
Name: DOB: Age:Sex:Living With You? Adopted/Biological?
Name: DOB: Age:Sex:Living With You? Adopted/Biological?
Name: DOB: Age:Sex:Living With You? Adopted/Biological?
Briefly describe any custody arrangements/issue:
OTHERS LIVING IN YOUR HOME:
Name: DOB: Relationship: Name: DOB: Relationship:
PETS/ANIMALS:
Briefly describe any pets or animals living inside or outside of your home:
MEDICAL SUMMARY:
FATHER’S HEALTH:
- Father’s General Health:
- Father’s Physician:
- Physician Address:
- Please check if you currently have or ever have had any of the following:
Tuberculosis Cancer
Diabetes (type I) Herpes
Diabetes (type II) HIV / AIDS
High Blood Pressure Tumor (non-cancerous)
Hepatitis A Operations
Hepatitis B Seizures
Hepatitis C Stroke
Mental Illness Heart Disease
Alcohol or Substance Abuse
- Explanation:
- Date of Diagnosis:
- Prognosis:
- Medication prescribed:
- Treatment prescribed:
MOTHER’S HEALTH:
- Mother’s General Health:
- Mother’s Physician:
- Physician Address:
- Please check if you currently have or ever have had any of the following:
Tuberculosis Cancer
Diabetes (type I) Herpes
Diabetes (type II) HIV / AIDS
High Blood Pressure Tumor (non-cancerous)
Hepatitis A Operations
Hepatitis B Seizures
Hepatitis C Stroke
Mental Illness Heart Disease
Alcohol or Substance Abuse
- Explanation:
- Date of Diagnosis:
- Prognosis:
- Medication prescribed:
- Treatment prescribed:
LEGAL INFORMATION
If the answer to any of the following questions are “yes”, please provide a detailed explanation in the space below. Answering yes does NOT automatically disqualify you from participating in the Hosting Program. Failure to disclose material information could make you ineligible to complete the hosting process.
NOTE: Include any traffic offenses such as DUI and Suspended License
- Have you ever been questioned, arrested, charged, and/or convicted of any crime including but not limited to shoplifting, fraud, theft, prostitution, solicitation, DUI, DWI, domestic violence, child abuse, assault, or possession of a controlled substance? Respond “yes” even if you were not involved or if you initiated the “complaint”.
Father Mother If Yes, please explain:
- Is there any reason that you would not be approved for FBI and/or State background checks?
Father Mother If Yes, please explain:
- Do you have a history of drug or alcohol abuse?
Father Mother If Yes, please explain:
- Has your application to adopt or foster parent ever been rejected by any other adoption or child-placing agency?
Father Mother If Yes, please explain:
- Have you ever been subject to an unfavorable home study?
Father Mother If Yes, please explain:
- Do you have an approved home study?
Father Mother If Yes, please explain:
- Have you ever had parental rights terminated by a court of law?
Father Mother If Yes, please explain:
HOME STUDY:
- Do you have a current approved home study? If yes, please complete the following:
- Home Study Agency:
- Social Worker:
- Agency Phone Number: Agency Fax Number:
- Agency Address:
- Is your home study provider Hague Accredited?
HOSTING PREFERENCES:
- Are you interested in volunteering to help: YES NO
- Desired age and sex of children to host: boy girl sibling group no preference
- Additional Comments:
- Why are you interested in hosting?
- Please list the activities you plan to do during the hosting period:
(ie biking, trips, etc)
Note: While we attempt to match your preferences as close as possible, we can’t guarantee exact matches regarding a host child can be met.
HOST PROGRAM PARTICIPATION AGREEMENT:
Please check each statement signifying your
CHILDREN’s NEEDS:I/We are aware that orphan children may have issues that require time and attention.
HOST DONATIONS:I/We understand that the hosting donation in the amount of $2950 per child, (and $2950 for each additional sibling) covers each child's international travel costs, insurance, in-country transportation, document preparation, in-country-administrative expenses, visa, and passport expenses.
DEPOSIT:I/We understand and agree to submit a $250 deposit donation if we wish to place a child on hold. Children can only be held for 24-48 hours without a deposit donation. The deposit donation is non-refundable
DEPOSIT RECEIPTS:I/We agree (as a New Host Family or a Re-Host Family) to forward the deposit receipt immediately to our P143 Regional Coordinator via email so the host child’s orphan court may secure the child for hosting.
DONATION DUE DATES:I/We understand and agree that if we are approved as a host family, we will submit a first donation of $1000 per child; normally 7 days after placing child on hold. A second donation of $850 is due no later than 30 days later. and the final donation of $850, bringing our total donation to $2950 per child, is due no later that 45 days prior to your host child’s arrival. (Specific donation dates/deadliness will be provided.)
TRANSPORTATION:I/We understand as a host family, we must make additional arrangements to meet, pick up, and return host child/ren to arrival airports (TBD) at our expense. In addition, we, as a host family, must provide for an adult chaperone to travel with our host child, which could be a chaperone of the program or the host family.
CHAPERONE HOUSING:I/We understand that we are required to host a chaperone in our home for a minimum of 1 week. If we cannot provide lodging for a chaperone in our home we agree to provide lodging through another source in the local vicinity.
HOST PARENT TRAINING:I/We understand that each host parent is required to attend one of three available online Host Parent Training Courses provided by P143, Inc. When re-hosting a child, host parents must repeat Online Host Parent Training annually.
CAMPS & SITTERS:I/We understand that at least one parent must be home with the host child/ren during the host season. Only 1 week of day camp or an approved sitter is allowed. Any additional caregivers must be over the age of 21 and have a current state background check on record with Project 143.
TAX DEDUCTIBLE/NO REFUNDS:I/We understand that all money given/paid by our family to Project One Forty Three is considered a tax-deductible donation and CANNOT be refunded. Receipts for tax purposes will be provided.
PHOTOGRAPHS: I/We understand that all photographs utilized of host children and families by Project One Forty Three is considered to be the property of P143 and may be used for promotional purposes now or in the future. No photographs of children are to be posted on social media or the internet unless the child appears unidentified in a group setting.
HEALTH INSURANCE:I/We understand that Host Families are responsible for medical costs not covered by insurance. We are aware the medical insurance provided is a limited coverage – medical insurance for travelers.
UNFORESEEABLE CIRCUMSTANCES:Underextremelyrarecircumstances,achildmaybepulledfromtheprogramduetoillnessorotherunforeseeable causes in the child's country of origin.We will do everything in our power tooffer an alternate host child or transfer unspent money to the next host program for an affected family. However, many non-refundable program related paymentscoverairline & train tickets, passports,visas, medical insurance etc.,during the prior monthsof the host child’sarrivalwhichcan notberecouped, refunded or used later.
DIGITAL SIGNATURE:DATE: DIGITALSIGNATURE:DATE:
HOST PROGRAM DONATIONS:
Typical host program donations are applied to the following expenses:
DESCRIPTION AMOUNT
Document preparation (per participant):...... $525
Apostille documents, Translation and certification of documents
Child's Travel and Related Expenses:...... $2050
In-country transportation to/from airport, Passport and US Visa
Medical Insurance:...... $75
Portion of Chaperone Expenses:...... $200
Chaperone's insurance, Chaperone expenses, Chaperone's airfare
Miscellaneous:...... $100
TOTAL...... $2950
FEE REDUCTIONS:
GRANTS:
The child(ren) we are hosting includes a Host Grant. YES NO
- Funds provided by a source other than P143 to be deducted from a host child’s final host balance.
SCHOLARSHIPS:
The child(ren) we are hosting includes a Host Scholarship. YES NO
- Funds placed on child, provided directly by Project 143, to be deducted from the final host balance.
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HOST PROGRAM FINANCIAL AGREEMENT:
NO REFUNDS POLICY:
In accordance with IRS regulations, Project 143 enforces a strict “No Refunds” policy for donations made to the orphan host program. To refund “donations” made to a nonprofit organization, such as Project 143, goes against our 501c3 certification and jeopardizes our nonprofit status to do so.
P143’s No Refund Policy applies to the following but may not be limited to:
- $250 Deposit is always NONREFUNDABLE regardless of circumstances.
- Removal of a host child from a host family’s home for any reason.
- Cancellations by a host family prior to host child’s arrival.
- Host family failed background check.
- A Home Safety Report resulting in a “Non-Recommendation”.
TRANSACTION ADJUSTMENTS POLICY:
- Project 143 recognizes circumstances wherein a transaction adjustment is necessary.
- A portion of donations may be available for transferring to the next host season.
- The donation amount available for transferfor a host family will vary by date.
- Situations applicable for transaction adjustments are determined at Project 143’s discretion.
- Donations are utilized throughout the pre host season, from the initial host family deposit to the arrival of the children; therefore, donations already utilized cannot be transferred to another host season.
Non transferrable funds may include:
- Airline tickets
- Passports
- Visas
- Train tickets
- Medical insurance
EXAMPLE: A situation that may warrant a transaction adjustment:
- Removal of a child from the host program by a foreign government. In this situation, an alternate host child will be recommended.
FUNDRAISING DONATION POLICY:
Monies raised on behalf of a family’s fundraising activities are non-refundable.
Donations made through a family’s fundraising resources:
- may be transferred to the next consecutive host program/host season only.
- may be transferred and utilized toward hosting another child.
Fundraising donations achieved through Razoo.com or YouCaring.com should be addressed directly with those organizations. RAZOO(866) 437-1952
CANCELLATION POLICY:
A cancelled commitment to host a child by a family, regardless of reason, negatively impacts a child’s chances of having a host family. By holding a child off the photo listing for more than 2 weeks through a financial commitment hinders that child’s chances of being matched with a family.
Funds already donated by a host family,who then breaks their hosting commitment, will remain with the host child and will not be refunded.
Once a family cancels, their nonrefundable donations will be allocated, in the form of a grant, to reduce the child’s host donation fees in an effort to quickly identifying a new host family for the host child.
Donation funds utilized for the child grant are drawn from the cancelling host family’s initial host deposit and/or any other donation payments already made.
Project 143 may cancel a host family’s hosting event with the program due to a host parent’s neglect in responsibilities. Such warranted actions include:
- Extending host donation payments beyond the host schedule due dates.
- Failure to submit required host documents within 30 days of paying a host child’s deposit.
DIGITAL SIGNATURE:DATE: DIGITAL SIGNATURE:DATE:
HOST FAMILY RESPONSIBILITIES:
Host Family must agree to do the following:
CRIMINAL BACKGROUND CHECK: Provide Consent for Criminal Background and Child Abuse Clearances
CHILD SAFETY AGREEMENT:Sign Child Safety Agreement
OVER 18:Obtain State Background Check for all adults over the age of 18 in the household, or any caregivers (such as nanny or babysitter).
REFERENCES:Obtain (4) letters of reference from persons other than family members.
MEDICAL SUMMARY:Obtain a medical conclusion from your family doctor (If you have not had a physical in 3 years or more)
HOME SAFETY VISIT:Obtain Home Safety Visit, done by a social worker
HEALTH CARE:Provide any minor medical care that might be required for the child/ren during their visit that is not covered by group travel insurance policy.
WEEKLY CONTACT:Have a minimum of two phone conversations a week with your family’s P143 Regional Coordinator regarding the child/ren, a minimum of 1 phone conversation weekly with the child’s chaperone residing in the USA and 1 phone conversation/email conversation or Skype conversation per week with the child’s designated correspondent in home country.
INTENT TO RETURN:Agree to return child/ren to their country of origin at end of the program. Sign Intent To Return form.
PHOTOS:Send pictures of the child/ren with family and Host Reports to Project One Forty Three weekly
CHAPERONE HOUSING:To host and/or assist with room and board for any escorts/chaperones traveling with the children.
TIMELY DONATIONS:To pay hosting donations by defined deadlines.
SITTERS: Obtain a child sitter utilized by the host family that is over the age of 21. Have one host parent remain with the host child at all times unless staying with an approved sitter no more than 1 full week straight or no more than 1 week of day camp. (Day camp leaders must also have a criminal background check. Overnight stays or camps are NOT permitted.)
SLEEPING ARRANGEMENTS: Provide host child with their own bed.
TRANSPORTATION:Agree to pick up and return host child at the closest arrival airport/departure airport designated by P143. To be determined by number of host families. Host families are responsible for any costs incurred beyond the international flight terminal to and from their host home.
Children will be returned to their home country. NO EXCEPTIONS! (Initials) (Initials)
NOTE: Participating countries require final host family approval by an Accredited Agency. All forms are sent to Project 143’s governing agencyfor final approvals and paperwork. Governing agencies will vary according to child’s country of origin. All host program communication is maintained by Project One Forty Three, Inc.
I/We have honestly answered all of the above questions, and confirm that the information in this form is true and correct. I/We understand that providing false, incomplete, or misleading information will result in an immediate disapproval of our application, and if the process has already begun, an immediate termination of the process without refund.
DIGITAL SIGNATURE:DATE: DIGITAL SIGNATURE:DATE:
CHILD STATUS ACKNOWLEDGEMENT:
Project One Forty Three, Inc. is a non profit orphan hosting organization that brings orphaned children from a particular country to stay with host families in the United States for a period of 4-11 weeks during the winter or summer season. Project 143 is not an adoption agency, nor a “host-to-adopt” program and doesnotperform services for international adoption.
Information about a child is communicated via Social Workers and/or Orphanage Directors. While Project 143 does all we can to obtain accurate information, by law, only an adoption agency has legal access to all of the details. Please also
note: the information provided to families is confidential, must be protected as private information and cannot be disclosed without a valid consent. Most countries do not allow the sharing of information about their children on the internet/social media.
Our goal, as a hosting agency, is to make strong connections with kids and develop a strong bond with the host parents that will continue long after hosting, with or without adoption. And, if children are available for adoption, create an environment to build even stronger bonds. Please remember, P143 rules do not allow for any communication between families and children about adoption. Adoption is never discussed with a child during the hosting period.
Families that do wish to pursue adoption may contact an adoption agency to inquire further, once the host child has returned to their country. Until a host family has heard directly from the Adoption Authority in the child’s country, an adoption status cannot be guaranteed.
Please initial your understanding and compliance:
I agree to maintain the confidentiality of all Project 143 host children, their personal and private information of which I may be privy of receiving.
I agree to refraine from speaking with my host child/ren about adoption.
I understand that orphans participating in the hosting program may be “social orphans” with siblings or relatives that are still alive.
I understand that a host child’s adoption status may not be 100% accurage due to the limited information provided by their caregivers, social workers and orphanage directors.
I understand that a host child may have siblings or extended families members that are unknown and may surface at a later date that could affect the status of a host child’s availability for adoption.
I understand Project 143 has made every effort to bring only those orphans who have a great probability for success participating in the hosting program.
I have read this Child Status Ccknowledgement and do hereby demonstrate my understanding and compliance concerning the privacy and limited information available in regard to the host children by affixing my signature and the date below.
DIGITAL SIGNATURE:DATE: DIGITAL SIGNATURE:DATE:
(Host Father Signature)(Host Mother Signature)
CHAPERONE HOUSING REQUIREMENT:
Ministering through international exchange by hosting a chaperone is a wonderful experience. You will be blessed and learn so much about another country and culture. Wouldn’t it be wonderful to host a chaperone for a week? It is a whole new cultural event for the chaperone just being with your family. What a fun time for a foreign visitor and your family!
CHAPERONE MINISTRY:
Chaperones are vital to our program and from the birth of P143, housing chaperones has been a ministry in itself embraced by the host families. We also encourage prior host families and other interested families who would like to participate in P143’s Chaperone Housing Ministry to do so. When speaking with our past chaperones we asked what is it about chaperone hosting that drew them to P143? The most popular answer? “To be able to spend time with an American family in their home.” Wow, what a compliment!
REQUIREMENT:
As part of the Project 143 Host Program, Hosting an international orphan requires all Host Families to “house” a chaperone for 1 week during the host season OR provide a substitute family that will house a chaperone in your place.
DURATION:
Hosting an international orphan requires the host family to commit and choose at least one available week to house a chaperone during the host season. Our chaperones are the legal guardians of the children while they are traveling within the USA. Without chaperones, orphan children would not be able to experiencethe wonderful benefits of our hostprogram.
ACCOMMODATIONS:
Chaperones are needed across the United States. Accommodations must include their own bed but not their own private bedroom. Empty homes or apartments are not accepted form of housing for chaperones for multiple safety reasons. Should a host family be unable to accommodate a chaperone, that host family must provide a substitute family who will house a chaperone in their place.
ENTERTAINMENT:
Any host family residing within a 2 hour radius of a chaperone are required to entertain the chaperone for one day. Dinner out, shopping, bowling, movies etc. will assist the chaperone host family and provide the chaperone with a wonderful time while in America. Please be prepared to reach out and help when a chaperone is residing near you.
HOUSING STIPEND:
P143 will provide a stipend per host family of $75*.During the week of Christmas the stipend will be$150* to help with gifts, travel and food. Many host families direct P143 to give the stipend to the chaperone or to use it toward helping an orphan. Please specify below how you would like to use your Housing Ministry Stipend.
- To help offset costs incurred by my family while hosting a chaperone in our home.
- To help offset costs for the chaperone during his/her stay in America.
- To help increase an orphan’s chance at being selected for hosting next season.
*Please go to to submit your housing stipend designation.