Questionnaire for the Head of a Nurturing Family

The following questions are intended to provide us with an accurate representation of your family.
This information will help ensure a compatible placement of a Client within your Nurturing Family.

As you answer the questions below, it is only natural that you may have questions about our
organization or the nurturing experience itself. We encourage you to talk with a
member of our staff to gain a better understanding of the role of the Nurturing Family.

The term "Nurturing Family" encompasses many home situations. Whether you are married,
with or without children, a single parent, or a single person, we are most appreciative of your
interest in becoming a Nurturing Family.

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	Date	/ /
A. Basic Information
	Your full name        Birthdate
	Address
	City/State Zip
	Home phone:    ()        Fax ()
	Business phone:    ()        Fax ()
	Email address
	Race	Religion
	Height	Weight
	Location of Home      Rural      Suburb      Urban
	If rural, what is your closest large city?
	Please list two references (non-family members) who have known you for over five years. Please include their names, addresses, and phone numbers to facilitate our contacting them. A.
	B.
	Please list the social, religious, volunteer and business organizations of which you are a member. Please provide information about your memberships and any other "volunteer" activities in which you are involved.
	Organization or Activity	Length of Membership	Leadership Positions Recognition and Awards