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Attached is an application for consideration in the 2009 Ulster Project of Greater Hutchinson, Inc. Completion of this application is not a guarantee of participation. All applicants will be interviewed and twelve teens are then selected by the Host Families Committee. Upon acceptance in the Ulster Project, a physical form signed by a doctor is required.

Background checks will be conducted on everyone over the age of 18 living in the home. Please provide the following information for background checks:

Full name other names used Date of birth

____________________________________________________________

For Ulster Committee use only:

Date Application Received___________________________

Comments:

If you have questions or to turn in your application please contact Vicki Foss at 620-474-2150.

Thank you for your interest in the Ulster Project.
The Ulster Project of Hutchinson

Full Name _____________________________________________________________

Address: _______________________________________________________________

Zip Code: ________________ E-mail Address: ___________________________________________

Phone (Including area code): _______________________________

Birth Date (MM/DD/YY): _________________________________ Name You Go By: _______________

Parents’/Guardians’ Names: __________________________________________________________________

Protestant or Catholic Your Church/Parish Name:____________________________________________

Your School: ______________________________________________________________________________

T-Shirt Size : Please Circle One (Adult Size) S M L XL

The information on this form will be used to match you with your host teen and family.

Therefore, if you complete the questions carefully and honestly, your chance of a suitable match will be improved.

YOUR INTERESTS

MUSIC What kind do you like? _________________________________________________ Do you sing? Y N

What instruments do you play? __________________________________________________ Do you dance? Y N

SPORTS What do you like? ________________________________________ Do you swim? Y N

What sports do you play? ____________________________________________________________________

COMPUTERS Are you interested in computers? Y N Do you have access to a computer? Y N

Where do you use the computer most? Home ____ School _____ Other _____

FOODS What are your favorite foods? _________________________________________________________

What are your least favorite foods? _____________________________________________________________

Are you a vegetarian? Y N

Do you have any food allergies? Y N

SOCIAL ACTIVITIES Never Seldom Often

Watch TV _____ _____ _____

Enjoy Parties _____ _____ _____

Talk with 1 or 2 friends (rather than group) _____ _____ _____

Comfortable talking in front of a group _____ _____ _____

WITH THIS FORM, PLEASE INCLUDE - A short Biography and a family photo

TELL US ABOUT YOU

(This should be a short biography covering the following topics, What are your hopes or plans for the future, What are your favorite school subjects, Why are you interested in this project and what do you hope to gain from this experience, What special talents, skills or personality can you bring to this project, How do you spend your free time, include church and club activities)

REMEMBER THIS IS YOUR OPORTUNITY TO TELL US ABOUT YOU IN YOUR OWN STYLE. PLEASE FEEL FREE TO USE ADDITIONAL PAGES FOR THIS BIOGRAPHY.

ADDITIONAL FAMILY INFORMATION

Father’s Name: ____________________________________ Occupation: _____________________________

Mother’s Name: ___________________________________ Occupation: _____________________________

Children:

Name: ___________________________ Age: _____ School: _____________________________

Please list other adults that may be living with you during this project:

__________________________________________________________________________________________

Do you have pets in your home? ______ If yes, what kind? _________________________________________

Do you have any allergies towards pets? Y N

Do you have access to any special recreational facilities? (pool, tennis courts, lake, etc.)

Automobile insurance? Y N Homeowners insurance? Y N

Please provide references that we can contact (THIS IS REQUIRED)

Family (Pastor or clergy)

Name: __________________________________________ Phone: _________________________________

Address: ________________________________________ Relationship: ____________________________

Signature: ___________________________________________ (Please have your pastor or clergy sign)

Teen (Teacher, counselor)

Name: __________________________________________ Phone: _________________________________

Address: ________________________________________ Relationship: ____________________________

Family or Teen (Longtime friend, church member)

Name: __________________________________________ Phone: _________________________________

Address: ________________________________________ Relationship: ____________________________

What are your family interest, hobbies, or talents? _________________________________________________

What do you do for fun?______________________________________________________________________

What are your talents/hobbies?_________________________________________________________________

__________________________________________________________________________________________

What are your goals and/or plans for the future?___________________________________________________

__________________________________________________________________________________________

What are your favorite classes in school?_________________________________________________________

__________________________________________________________________________________________

What school/church activities or clubs do you participate in?_________________________________________

__________________________________________________________________________________________

Why do you want to participate in the Ulster Project?_______________________________________________

__________________________________________________________________________________________

Describe your personality?____________________________________________________________________

__________________________________________________________________________________________

Have you ever traveled outside of Kansas?_______________________________________________________

__________________________________________________________________________________________

Outside the United States?____________________________________________________________________

__________________________________________________________________________________________
The Ulster Project of Hutchinson

Consent and Release Form

We, the undersigned Parents/Guardians of _______________________________________________________

do hereby consent to His/Her participation in this program and authorize Him/Her to travel under the direction and control of the Ulster Project of Hutchinson, according to the program requirements set up by the organization.

We hereby authorize the Ulster Project of Hutchinson, its committee members and/or its host parents:

To represent us before any medical institution where it may be necessary to send our Son/Daughter for medical care while He/She is under the authority and supervision of the Ulster Project of Hutchinson.
To authorize on our behalf any medical care that our child might need or might appear to need, including but not limited to surgery, blood transfusions, dental work and administration of medicine and anesthetics; such authorization is given with the understanding that we, the undersigned, incur and adopt all liability for expenditure relating to the foregoing medical care and hereby release the Ulster Project of Hutchinson from such liability and expenditures.
To represent us before any governmental agency or authority while He/She is under its custody.

In consideration of the foregoing, we, the undersigned, on behalf of ourselves and of our child, hereby release the Ulster Project of Hutchinson, its successors and/or assigns, and its host families to the full extent permitted by law from any and all liability, demands, claims, damages, actions, losses and expenses, including attorney’s fees and medical expenses for which the Ulster Project of Hutchinson or its representatives may become liable or answerable by reason of our child’s participation in the Ulster Project of Hutchinson. Further we agree on our behalf, and on behalf of our child, not to bring or enforce any claims for damages or expenses against the Ulster Project of Hutchinson, which may arise by reason of our child’s participation in the Ulster Project of Hutchinson and activities relation thereto.

I, parent/guardian, further understand that:

The information that I have provided on myself or my teen in the attached application may be verified, if necessary, by contacting persons or organizations named in this application, or by contacting any person or organization that may have information concerning our qualification. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless the Ulster Project of Hutchinson and the officers and volunteers thereof.
In signing this application, I have read the attached by-laws. I agree to comply with the policies, rules and regulations of the Ulster Project of Hutchinson. I affirm that the information I have given on this form is true and correct.

Please print in BLOCK LETTERS:

Date: (MM/DD/YY) ___________________________

Father’s/Guardian’s Name: ___________________________________________________________________

Father’s/Guardian’s Signature: ________________________________________________________________

Mother’s/Guardian’s Name: __________________________________________________________________

Mother’s/Guardian’s Signature: ________________________________________________________________

Witnessed by: _____________________________________________________________________________

Witness’ Address: __________________________________________________________________________

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