MN Wilderness Billet Application
Minnesota Wilderness Family Application 2013-14
A) Family Contact Information Last Name (Husband): _____________________ First: _____________________ Middle: _________________ D.O.B.:______________ Birthplace: ____________________ SSN*: ________________ Last Name (Wife): _____________________ First: _____________________ Middle: ____________________ D.O.B.:______________ Birthplace: ____________________ SSN*: ________________ *ALL APPLICANTS ARE SUBJECT TO BACKGROUND CHECKS (THE REASON WE ASK FOR SSN)
Home Address: ____________________________________________________________________________ Years in the Cloquet Area: ________ Previous Address:____________________________________________ Current Home Number: _______________________ Husband’s Cell Number:_______________________
Wife’s Cell Number___________________________
Email: (list all e-mail addresses you would like to have on the contact list) ____________________________________________________ home work (circle one) ____________________________________________________ home work (circle one) ____________________________________________________ home work (circle one) Best Way(s) to contact you? Husband: ___ Email ___ Cell Phone ___ Home Phone ___ Work Phone Wife: ___ Email ___ Cell Phone ___ Home Phone ___ Work Phone
B) Family’s Employment Background Husband’s Occupation: _________________Employer’s Name:___________________________________ Employer’s Address: _____________________________________________________________________ Work Phone Number: ____________________ Number of Years Employed: _____ If less than three, please list previous employer’s name and address:_______________________________ Wife’s Occupation: ______________________ Employer’s Name: _________________________________ Employer’s Address: ______________________________________________________________________
Work Phone Number: ____________________ Number of Years Employed: _____ If less than three, please list previous employer’s name and address:_________________________________ C) Family Members Information Name (Child 1):______________________________
Age:________
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Name(Child 2):___________________________ ___
Age:________
School:____________________ ________________
Male / Female (Circle One)
Male / Female (Circle One)
Living in the house: Yes / No (Circle One)
Name(Child 3):______________________________
Age:________
Male / Female (Circle One)
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Name(Child 4):___________________________ ___
Age:________
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Male / Female (Circle One)
*IF A CHILD IS 16 YEARS OLD OR OLDER, PLEASE PROVIDE THEIR DATE OF BIRTH
D) Background on Your House and Lifestyles 1. Does anyone other than your children live in your home with you? _____ Yes ____ No If Yes, who? _________________________________________________________________________ 2. Do you have any pets? (Please list types, how many and inside or outside) If Yes, What? _____ Dog _____ Cat _____ Other (list) 3. Have you ever hosted an exchange student or player before? _____ Yes ____ No 4. Please write a brief explanation of why you would like to billet a Wilderness Player:
5. What are your household work schedules? Does it involve travel?
6. Family Hobbies/Activities?
7. What household chores would a player be responsible for?
8. Describe the accommodations that will be available for a player(s):__________________________________________ __________________________________________________________________________________________________ a. Will the player(s) have their own room? Yes / No (Circle One) b. Will the player(s) have their own bathroom? Yes / No (Circle One) 9. Distance from your home to the Northwoods Credit Union Arena:___________________________________ 10. How many players are you interested in hosting? __________ 11. Would you be supportive if the player living with you was traded? _____yes _____no
If so, would you take new player? _____ Yes ____ No
12. Do you have internet access at your home? _____ Yes ____ No If yes, is it wireless? _____ Yes ____ No 13. Political Views (Not Required):______________________________________________________________ 14. What is your Religious Denomination (Not Required):___________________________________________ E) Billeting Requirements and Rules The team asks its host families to provide a separate bedroom for the player or players. It is also requested that if the players are sharing a room, that each player have their own bed. Players are expected to be an involved member of the household, which includes but is not limited to: 1) Follow all team rules and curfews 2) Follow any additional rules or curfews you may have 3) Always maintain a clean room 4) To help out with normal household duties (dishes after dinner, occasional cooking, cleaning, etc) 5) They are to perform their own laundry Meals (breakfast, lunch and dinner) are to be eaten with the host family unless other arrangements for the day have been made between the player and the family. Please be aware that many players have a large food requirement because of the physical demands of playing junior hockey.
F) References Please list three references (non-family members who have known you for at least three years) who we may contact: 1) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________ 2) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________ 3) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________
Thank you from the Minnesota Wilderness Staff!
For more information please contact: Joshua Petrich Assistant Coach Minnesota Wilderness
Dan Daikawa Assistant Coach Minnesota Wilderness
(763) 439-9125 Cell [email protected]
(651) 208-4628 Cell [email protected]
WHEN APPLICATION IS COMPLETE, PLEASE SUBMIT IT ONE OF THE TWO FOLLOWING WAYS: Email it to Joshua Petrich at [email protected] Or Mail it to the Minnesota Wilderness at: 1102 Olympic Drive Cloquet, MN 55720
A) Family Contact Information Last Name (Husband): _____________________ First: _____________________ Middle: _________________ D.O.B.:______________ Birthplace: ____________________ SSN*: ________________ Last Name (Wife): _____________________ First: _____________________ Middle: ____________________ D.O.B.:______________ Birthplace: ____________________ SSN*: ________________ *ALL APPLICANTS ARE SUBJECT TO BACKGROUND CHECKS (THE REASON WE ASK FOR SSN)
Home Address: ____________________________________________________________________________ Years in the Cloquet Area: ________ Previous Address:____________________________________________ Current Home Number: _______________________ Husband’s Cell Number:_______________________
Wife’s Cell Number___________________________
Email: (list all e-mail addresses you would like to have on the contact list) ____________________________________________________ home work (circle one) ____________________________________________________ home work (circle one) ____________________________________________________ home work (circle one) Best Way(s) to contact you? Husband: ___ Email ___ Cell Phone ___ Home Phone ___ Work Phone Wife: ___ Email ___ Cell Phone ___ Home Phone ___ Work Phone
B) Family’s Employment Background Husband’s Occupation: _________________Employer’s Name:___________________________________ Employer’s Address: _____________________________________________________________________ Work Phone Number: ____________________ Number of Years Employed: _____ If less than three, please list previous employer’s name and address:_______________________________ Wife’s Occupation: ______________________ Employer’s Name: _________________________________ Employer’s Address: ______________________________________________________________________
Work Phone Number: ____________________ Number of Years Employed: _____ If less than three, please list previous employer’s name and address:_________________________________ C) Family Members Information Name (Child 1):______________________________
Age:________
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Name(Child 2):___________________________ ___
Age:________
School:____________________ ________________
Male / Female (Circle One)
Male / Female (Circle One)
Living in the house: Yes / No (Circle One)
Name(Child 3):______________________________
Age:________
Male / Female (Circle One)
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Name(Child 4):___________________________ ___
Age:________
School:____________________ ________________
Living in the house: Yes / No (Circle One)
Male / Female (Circle One)
*IF A CHILD IS 16 YEARS OLD OR OLDER, PLEASE PROVIDE THEIR DATE OF BIRTH
D) Background on Your House and Lifestyles 1. Does anyone other than your children live in your home with you? _____ Yes ____ No If Yes, who? _________________________________________________________________________ 2. Do you have any pets? (Please list types, how many and inside or outside) If Yes, What? _____ Dog _____ Cat _____ Other (list) 3. Have you ever hosted an exchange student or player before? _____ Yes ____ No 4. Please write a brief explanation of why you would like to billet a Wilderness Player:
5. What are your household work schedules? Does it involve travel?
6. Family Hobbies/Activities?
7. What household chores would a player be responsible for?
8. Describe the accommodations that will be available for a player(s):__________________________________________ __________________________________________________________________________________________________ a. Will the player(s) have their own room? Yes / No (Circle One) b. Will the player(s) have their own bathroom? Yes / No (Circle One) 9. Distance from your home to the Northwoods Credit Union Arena:___________________________________ 10. How many players are you interested in hosting? __________ 11. Would you be supportive if the player living with you was traded? _____yes _____no
If so, would you take new player? _____ Yes ____ No
12. Do you have internet access at your home? _____ Yes ____ No If yes, is it wireless? _____ Yes ____ No 13. Political Views (Not Required):______________________________________________________________ 14. What is your Religious Denomination (Not Required):___________________________________________ E) Billeting Requirements and Rules The team asks its host families to provide a separate bedroom for the player or players. It is also requested that if the players are sharing a room, that each player have their own bed. Players are expected to be an involved member of the household, which includes but is not limited to: 1) Follow all team rules and curfews 2) Follow any additional rules or curfews you may have 3) Always maintain a clean room 4) To help out with normal household duties (dishes after dinner, occasional cooking, cleaning, etc) 5) They are to perform their own laundry Meals (breakfast, lunch and dinner) are to be eaten with the host family unless other arrangements for the day have been made between the player and the family. Please be aware that many players have a large food requirement because of the physical demands of playing junior hockey.
F) References Please list three references (non-family members who have known you for at least three years) who we may contact: 1) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________ 2) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________ 3) Name:______________________________
Address:_____________________________________
Phone:____________________ _____ Relationship to you:__________________________________________
Thank you from the Minnesota Wilderness Staff!
For more information please contact: Joshua Petrich Assistant Coach Minnesota Wilderness
Dan Daikawa Assistant Coach Minnesota Wilderness
(763) 439-9125 Cell [email protected]
(651) 208-4628 Cell [email protected]
WHEN APPLICATION IS COMPLETE, PLEASE SUBMIT IT ONE OF THE TWO FOLLOWING WAYS: Email it to Joshua Petrich at [email protected] Or Mail it to the Minnesota Wilderness at: 1102 Olympic Drive Cloquet, MN 55720
