Haiti Refugee Survey - MiddleTN Orphan Alliance (MTOA)

1. MTOA - Haiti Survey

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33% of survey complete.

The tragedy in Haiti has caused a tremendous crisis for orphans and many of these children are being sent to the US for temporary and perhaps permanent care. In some communities like Chicago and South Florida planeloads of children are already in route. We are trying to be proactive here in MiddleTN and build a list of willing families that would be willing and qualified to accept one or more of these children should we be called upon.

IF YOU ARE INTERESTED, and HAVE A COMPLETED BACKGROUND CHECK, FINGERPRINT CHECK, AND HOME STUDY, PLEASE FILL IN THE FOLLOWING. This situation is very fluid and there may be more requirements. This would likely be respite care or temporary care situation. We will create a mailing list of interested parties to share further information as we learn it.

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* 1. Please enter your basic contact information.

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. How many adults are in your household over the age of 18?

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* 3. Please enter the information regarding your home church.

Pastor's Name

Church Name

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 4. Has everyone over 18 in your family completed a fingerprint check and background check?

Yes

Not sure

Please comment if only some of the family has completed currently

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* 5. Do you believe your family would be willing and equipped to take in a special needs child (Physically or mentally handicapped)? (Many children are newly amputees).

Yes

Maybe

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* 6. Do you have a completed Home Study?

Yes

What's a Home Study?

Comment if Necessary