Fort Lewis College

FLC Family Connection Program - Family Application

Please fill out the following application and then choose "Submit Application".

Required

Name
Last Name:
First Name(s):

Home Address
Street:
City:
State:	homeState
Zip:
Home Phone (xxx)xxx-xxxx:
Work Phone (xxx)xxx-xxxx:
Cell Phone (xxx)xxx-xxxx:
Email Address:

Summer Address
My summer address is the same as my home address
Street:
City:
State:	summerState
Zip:
Summer Phone (xxx)xxx-xxxx:

Additional Information
What are your interests?

Please list your occupation(s):

Number of family members in household:

Ages of children (if living in household):

Your preferred student would be what gender	Male Female No Preference

Your preferred student would share what cultural background?

Your preferred student would have what academic interests?

Do you have any pets?	Yes No

What type of pet(s) do you have?

Do you smoke?	Yes No

What languages, other than English, do you speak?

Would you be willing to be matched with more than one student?	Yes No

Would you be willing to have your students stay with you over breaks?	Yes No

Why are you interested in the FLC Family Connection Program?

By submitting this application, I agree to assume all risk of personal injury or loss, bodily injury (including death), damage to or loss of, or destruction of personal property, resulting from or arising out of my participation as a volunteer in the FLC Family Connection Program. I also release, waive, indemnify, hold harmless, and discharge Fort Lewis College from all claims, damages, and injuries arising out of my volunteer activities. I understand that a background check may be performed on myself and anyone else living in the household who is over 18 years of age, at no expense to us. I will be required to supply my social security number to HireRight when the company contacts me.

By submitting this application, I agree to assume all risk of personal injury or loss, bodily injury (including death), damage to or loss of, or destruction of personal property, resulting from or arising out of my participation as a volunteer in the FLC Family Connection Program. I also release, waive, indemnify, hold harmless, and discharge Fort Lewis College from all claims, damages, and injuries arising out of my volunteer activities. I understand that a background check may be performed on myself and anyone else living in the household who is over 18 years of age, at no expense to us. I will be required to supply my social security number to HireRight when the company contacts me.

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Fort Lewis College

FLC Family Connection Program - Family Application

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