Community Connections Host Form

All fields required for submission. Please use N/A for not applicable

Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone*

Email*

Summer Address

I have a different address in the summer

Summer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What are your interests?*

Please list your occupations*

Number of family members*

Ages of children*

Your Community Connections Program student would have what academic interests?*

Are you interested in supporting a student athlete?*

If you answered yes above, any particular sport?

Your preferred student would be what gender?*

What languages other than English do you speak?*

If you have pets, please list what type*

Would you be willing to host more than one student?*

Why are you interested in the Community Connections Program?*

Consent*

I agree to the agreement below.

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 Community Connections Program. I also release, waive indemnify, hold harmless, and discharge the University of Maine at Presque Isle from all claims, damages, and injuries arising out of my volunteer activities. I understand that a background check may be performed on me or my significant other, at no expense to the university. I understand I will be required to supply my social security number if a background check is required.

Acknowledgement

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 Community Connections Program. I also release, waive indemnify, hold harmless, and discharge the University of Maine at Presque Isle from all claims, damages, and injuries arising out of my volunteer activities. I understand that a background check may be performed on me or my significant other, at no expense to the university. I understand I will be required to supply my social security number if a background check is required.

Email

This field is for validation purposes and should be left unchanged.