MENTORSHIP PROGRAM APPLICATION THANK YOU for your interest in becoming a Family Alliance Host Family! The Family Alliance is a network of host families that commit to a year-long mentorship program to become trained in providing residential care for survivors of exploitation through their own homes while partnering with HER Campaign for wrap around resources and services. MENTORSHIP PROGRAM OUTLINEOur 2021 Family Alliance Mentorship Program launches June 2021. Mentorship commitment includes attending monthly 1-hour webinars lead by Leaders and Advisors in the anti-human trafficking industry throughout the country that specialize in best care practices for survivors of human trafficking. All mentees will also work through a leadership curriculum in weekly one-on-ones with the Family Alliance Directors as well as engage in homework including selected reading materials and additional online trainings. The tuition for each Family Alliance family (single or couple) is $250/month. Our investment model is intended to create a self-sustaining program that covers the cost of trainings, curriculum, and resources as well as investing in the survivors we serve through the Family Alliance Program. For more information on tuition and scholarships, please email Sammy Higgs at sammy@hercampaign.org. Personal InformationApplicant(s)* Single Couple Host Families can consist of a single or couple led household. Please specify your household. Applicant Name* First Last Applicant Birthdate* MM slash DD slash YYYY Applicant Gender* Male Female Applicant Current Employment* Working Part-Time Outside of the Home Working Full-Time Outside of the Home Work From Home Unemployed Applicant #2 Name First Last Applicant #2 Birthdate MM slash DD slash YYYY Applicant #2 Gender Male Female Applicant #2 Current Employment Working Part-Time Outside of the Home Working Full-Time Outside of the Home Work From Home Unemployed Email* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Secondary Phone Number Past ExperienceDo you have experience working with an organization or agency that serves survivors of complex trauma? (This can include human trafficking, domestic violence, sexual abuse, etc.)* Yes No What is the name of the organization or agency you have worked with? What was your position (if any) at the organization or agency? Are Applicant(s) willing to submit to a background check?* Yes No Residential InformationDo you currently own your home?* Yes No Type of Residential Structure? Single Family Home Multiple Family Home Apartment or Condo Duplex Other Who currently lives at this residence with you? (Please include names and ages)*Family Alliance CommitmentPlease share why you are interested in possibly becoming a Host Family?*Would you be willing to take in a survivor who is pregnant or has children?* Yes No Maybe Would you be willing to take in a survivor who has handicaps and/or disabilities?* Yes No Maybe When are you typically available during the week?*WeekdaysWeekendsEveningsI am flexibleReferencesPlease provide a character reference for applicant(s).Applicant Character Reference* Name Relationship to Applicant Phone Number Email Address Applicant #2 Character Reference Name Relationship to Applicant Phone Number Email Address Personal StoryWhat is your faith background?* Christian Islamic Hindu Buddhist Atheist Agnostic/No Preference Other If applicable, where do you worship regularly? Please share a little about your spiritual journey.*Do you have any physical, emotional or mental health challenges you would like us to be aware of? (If yes, please explain.)*CommentsThis field is for validation purposes and should be left unchanged. Δ