Homeowner Information

First Name *

Last Name *

Gender* Male Female

Age*

Household Information

Are you married? *
Yes No

Spouses Name

Do you have kids? *
Yes No

You are districted for what school:*

Select a district... North Paulding East Paulding South Paulding Paulding County Hiram

Kid's Names (first name only)

House Information

Address*

Address Line 2

City* State* Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip*

I live at this address

Do you have any pets?

Does anyone in your house smoke?

Agreement

I, for the week of Operation Poverty, assume limited responsibility of the children staying at my house and agree to not allow them, or myself, to have or partake in drugs, alchohal, or any other illegal or inappropriate actvity. Failure to meet these criteria can result in legal action taken by Operation Poverty Inc. or by an involved family or individual. Operation Poverty Inc. cannot be held liable for any illegal actions that happen on your property or any resulting law suits. REMEMBER: YOU ARE THESE CHILDRENS CARETAKER.

Electronic Signature

(by signing you agree to the above statement)

*