2019-2020 Host Family Application
Adopt-A-Buc is a student-host family program at Dawson Community College. Community members who apply
will be matched with a DCC student. Your role as a host family is to help the student find a home away from
home. This is for the student to visit a family and have a local support system not a live with you program. For
the safety of our students, a background check will be conducted on every individual living in a household over
the age of 18.
Family Type: Individual ____ Adults, no children ____ Adult with Children ____
Total # in Household: ___________
Home Address: ____________________________________________________________________
City: __________________ State: _______ Zip: _______________
“Parent” #1 Name: _____________________________________ Male/Female: _____ Age: _____
Preferred Phone: ______________________ Email: ______________________________________
Occupation and Place of Work: _______________________________________________________
“Parent” #2 Name: _____________________________________ Male/Female: _____ Age: _____
Preferred Phone: ______________________ Email: ______________________________________
Occupation and Place of Work: _______________________________________________________
List all children living in your home:
Name: ___________________________________ Gender: _______ Age: _______
Name: ___________________________________ Gender: _______ Age: _______
Name: ___________________________________ Gender: _______ Age: _______
Name: ___________________________________ Gender: _______ Age: _______
List non-related individuals living in your home:
Name: __________________________ Gender: ____ Age: ____ Relationship: _________________
Name: __________________________ Gender: ____ Age: ____ Relationship: _________________
List hobbies or areas of interest for the Adults (sports, music, arts, outdoors, etc… Be specific.):
_________________________________________________________________________________
List hobbies or areas of interest for the Children (sports, music, arts, outdoors, etc… Be specific.):
_________________________________________________________________________________
What languages, other than English, do you speak? ______________________________________
Your preferred student would be Female ____ Male ____ No preference ____
Your preferred student would be In-State ____ Out-of-State ____ International ____
Would you prefer… 1 student ____ 2 students ____ No preference ____
List all pets living in your home: ______________________________________________________
How often would you like to meet with your student? Monthly / Biweekly / Weekly
Please share why you and your family desire to participate in Adopt-A-Buc: __________________
______________________________________________________________________________________
____________________________________________________________________________
Background Check
Dawson Community College may obtain information about you from a third party consumer reporting agency. Thus, you
may be the subject of a “consumer report” which may include information about your character, general reputation,
personal characteristics, and/or mode of living. These reports may contain information regarding your criminal history,
social security verification, motor vehicle records (“driving records”), verification of your education or employment
history, or other background checks. You have the right, upon written request made within a reasonable time, to request
whether a consumer report has been run about you and to request a copy of your report. These searches will be
conducted by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 888.670.9564;
www.verifiedfirst.com. The scope of this disclosure allows Dawson Community College to obtain consumer reports now
and throughout the course of your volunteering to participate in programs at Dawson CC to the extent permitted by law.
Disclaimer:
By providing my signature below, I acknowledge that I have voluntarily signed-up to be a host family through the Adopt-A-
Buc program and I am giving permission that this information be shared with participants of the program, especially any
students matched with my family. I agree to allow Dawson Community College to utilize photos of me and my family on
the DCC website and social media, as well as on any Adopt-A-Buc marketing materials. I also acknowledge that I will not
give any monetary or other large gifts or tickets to my assigned student, nor will the student travel with the family on a
trip with extensive miles or expense.
___________________________________________ _______________
Signature, “Parent” #1 Date
___________________________________________ _______________
Signature, “Parent” #2 Date
Return this completed form.
Mail to:
Dawson Community College
ATTN. Jon Langlois
300 College Ave.
Glendive, MT 59330
Scan and Email to:
housing@dawson.edu
Additional applications and information about Adopt-A-Buc are available online at:
https://www.dawson.edu/students/campus-life/adopt-a-buc/
Revision 07/26/17 www.VerifiedFirst.com
DO NOT STAPLE
I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND
INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify
that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports”
and/or “investigative consumer reports” by (“Employer”) at any time aer receipt of
this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation,
any law enforcement agency, administrator, state or federal agency, institution, school or university (public or
private), information service bureau, employer, or insurance company to furnish any and all background information
requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 1-888-670-9564;
www.VerifiedFirst.com and/or Employer. I agree that a facsimile (“fax”), electronic or photographic copy of this
Authorization shall be as valid as the original.
New York applicants only: Upon request, you will be informed whether or not a consumer report
was requested by the Employer, and if such report was requested, informed of the name and address
of the consumer reporting agency that furnished the report. You have the right to inspect and receive
a copy of any investigative consumer report requested by the Employer by contacting the consumer
reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A
of the New York Correction Law.
New York City applicants only: You acknowledge and authorize the Employer to provide any notices
required by federal, state or local law to you at the address(es) and/or email address(es) you provided
to the Employer.
Washington State applicants only: You also have the right to request from the consumer reporting
agency a wrien summary of your rights and remedies under the Washington Fair Credit Reporting Act.
Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy
of a consumer report if one is obtained by the Employer.
Last Name First Name Middle Name
check box if no middle name
Social Security Number* ###-##-####
Date of Birth*
month/date/year Email Address
required
Driver’s License Number Issuing State*
Former Names/Aliases
separate aliases with comma
CURRENT ADDRESS FORMER EMPLOYER
Street Apt/Unit Company City, State
City State Zip Position Dates of Employment
Applicant Signature Date
PLEASE COMPLETE ALL FIELDS BELOW
*This information will be used for background screening purposes only and will not be used as hiring criteria.
ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK
Dawson Community College
click to sign
signature
click to edit
1
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Dawson Community College may obtain information about you from a third party consumer reporting agency
for employment purposes. Thus, you may be the subject of a “consumer report” which may include
information about your character, general reputation, personal characteristics, and/or mode of living. These
reports may contain information regarding your criminal history, social security verification, motor vehicle
records (“driving records”), verification of your education or employment history, or other background checks.
You have the right, upon written request made within a reasonable time, to request whether a consumer report
has been run about you and to request a copy of your report. These searches will be conducted by Verified
First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel. # 888.670.9564;
www.verifiedfirst.com. The scope of this disclosure allows Dawson Community College to obtain consumer
reports now and throughout the course of your employment for an employment purpose to the extent permitted
by law.
Signature: Date:
[End of Document]
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