WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE. 
IF ANY OF THE ABOVE INFORMATION IS DETERMINED TO BE WILLFULLY INCORRECTLY STATED,
WE ACKNOWLEDGE THAT NHFC HAS THE RIGHT TO DISQUALIFY US FROM FURTHER CONSIDERATION.

______________________________________________________________________________

HUSBAND                                                       DATE                                 SOCIAL SECURITY #

_____________________________________________________________________________

WIFE                                                                 DATE                                 SOCIAL SECURITY #

STATEMENT OF FAITH - WIFE

Please provide your personal response to each of the following questions regarding your faith. 
A separate response is requested for each adoptive parent. Handwritten responses are fine.

1) What is the significance of Jesus Christ in your life?

2) Describe how you became a Christian.

3) Describe your spiritual growth since becoming a Christian.

STATEMENT OF FAITH - HUSBAND

Please provide your personal response to each of the following questions regarding your faith. 
A separate response is requested for each adoptive parent. Handwritten responses are fine.

1) What is the significance of Jesus Christ in your life?

2) Describe how you became a Christian.

3) Describe your spiritual growth since becoming a Christian.

4) What bible verse do you feel you personally identify with most?  In other words, what would your "life verse" be and why?

5) Please read this Bible passage and write your personal  feelings. 1 John 1: 5-10

6) Please read this Bible passage and write your personal feelings.  James 1:27

ONLY FOR GEORGIA FAMILIES

LIST OF LOCAL DFACS OFFICES; CALL US IF YOU NEED ANOTHER ONE:

RELEASE AND REQUEST FOR INFORMATION

NEW HORIZONS FOR CHILDREN, INC.

PRIVATE CHILD HOSTING AGENCY

We (I) ____________________________________________, currently residing at ________________ ___________________________________________________, in ________________ County give our (my) permission and request that DFACS release to New Horizons For Children, Inc., a private child hosting agency, licensed in the state of Georgia, a copy of any information on our (my) family regarding:

            1)         Child Protective Services

            2)         Adoption (inquiry or assessment)

            3)         Foster Care (inquiry or assessment)

This information will be used for the purpose of completing an Adoptive/Host Family Assessment for the placement of a child through a hosting program overseen by New Horizons For Children Inc.

_____________________________________              ______________________________________

Father’s Signature & Social Security #                              Mother’s Signature & Social Security #

Date of birth ____________________                            Date of birth _____________________

Please return this completed form to:     New Horizons for Children, Inc.

                                                                  3950 Cobb Parkway

                                                                  Suite 708

                                                                  Acworth, GA  30101

                                                                  (678)574-4677 Fax: (678)574-4757

Parents: DO NOT FILL OUT THIS PORTION:

1)  Child Protective Services Report:           ____ NO ____ YES (please attach information)

2)  Adoption Inquiry/Assessment:                ____ NO ____ YES (please attach information)

3)  Foster Care Inquiry/Assessment:            ____ NO ____ YES (please attach information)

_______________________________          ___________________

Caseworker Signature                                      Date

_________________                                      ___________________

County                                                             Telephone Number                                                      

*INVESTIGATION AUTHORIZATION*

We hereby authorize New Horizons for Children, Inc. and/or its representatives, to pursue any investigation it deems necessary in order to properly evaluate us as a hosting and/or adoptive family. 

BOTH PARTIES MUST SIGN:

____________________________________            ______________________________________

Husband                                                                       Wife

______________                                                        ________________

Date                                                                             Date

FBI Clearance Request

1)  Complete the attached letter to the FBI.  All adults must sign the request letter.  YOU MUST put the deadline request (04/15/07) on the OUTSIDE of the envelope.
“For Possible Adoption: Please respond before October 15, 2007".

2)  Take the enclosed fingerprint cards to your local law enforcement (police) office.  Make sure your cards have your name, date of birth and place of birth filled out on them. 

3)  Include $18 per person in the form of a money order or certified check made payable to the Treasury of the United States.  Be sure to sign where required.

·        No personal checks or cash

·        Must be exact amount

·        If for a couple, family, etc., include $18 for each person

4)  Mail items #1, #2, and #3 to the following address:

            FBI

            CJIS Division – Record Request

            1000 Custer Hollow Road

            Clarksburg, West Virginia 26306

It takes about 3-4 weeks before you will receive your clearance letter.  It will probably be returned to you (not our agency), so please let us know as soon as you receive it and we will need the original.  

Date _________________

FBI

CJIS Division – Record Request

1000 Custer Hollow Road

Clarksburg, West Virginia 26306

To Whom It May Concern:

I will be hosting a child or children from another country (Russia, Latvia or Guatemala) this summer, and in order to be approved, I will need a copy of my FBI record for security purposes.  My name and return address is below:

Name     ____________________________________________________

Address ____________________________________________________

                          ____________________________________________________

Date of birth_____________ Social Security #_____________________

Phone Number_______________________

I have enclosed two completed fingerprint cards.  The fee of $18 made payable to the United States Treasury is also enclosed. I realize it must be a certified check or money order.

If it is possible, please process by October 15, 2007

Sincerely,

_______________________________

_______________________________

You must sign this statement indicating you understand and accept these two items. This document is needed immediately. There are no exceptions or NHFC can lose their non-profit status with the IRS.

IMPORTANT: All money donated to the hosting program will be used for the hosting program. If you change your mind after sending in funds, or if a child is canceled due to illness or other reason beyond our control, no money can be refunded. There are two reasons for this:

               1. We pay money to the airlines, passport offices, US Embassy, country partners for work done and others along the way to cover each child’s expenses. In most cases, none of this money is refundable for any reason. The airline will not allow changes or credits for future trips as they gave us a contracted group rate. If your child is canceled, we will try and offer an alternate child, but there is no guarantee. In most cases, we feel that God has some plan and we cannot intervene or make things different. Please realize that we will do everything we can to make sure your child arrives with the group. In 7 previous programs, we have only had 4 cancellations occur like this. It’s not the norm, but it has happened.

               2. For money given to a cause to be tax deductible, it cannot be given to purchase an item or receive a specified service. Therefore, by law, donations made to non-profits, are not refundable. We promise all money donated will be used towards the hosting programs. Consider it like this: If a group “over” fundraise for one program, then NHFC may use this money to purchase items needed by an orphanage for our next interview trip. Or the funds may help another family sponsor a child for the next program when they cannot afford to pay the entire amount. For example, on our September ’05 interview trip, we donated $600 to one orphanage who needed to purchase bedding and dishes for their children. The children in need were too old or in a situation where hosting was not appropriate. However, the children were in dire need.  In the past, we have provided reusable diapers, plastic bed sheets, clothes, shoes and bedding for children. In March 2006, we donated $500 for a TV, VCR set and (Russian) Disney movies for a handicapped orphanage to use with their younger children.

______________________________                 ______________________________

Husband’s Signature                         Date                Wife’s Signature                                Date