Becoming a Host Home Provider with Region V Systems


IMPORTANT:  This is a federally funded grant, serving the following rural counties:  Adams, Butler, Cass, Clay, Fillmore, Gage, Jefferson, Johnson, Lancaster (NOT the city of Lincoln), Nemaha, Nuckolls, Otoe, Pawnee, Polk, Richardson, Saline, Saunders, Seward, Thayer, Webster, and York.  Host Home Provider applicants must reside in one of these counties to be eligible to participate in our program.


The first step is to complete the Host Home Provider Application below (Note:  instructions to sign a release for us to conduct your background check will come later, inclusive for all members of the household age 19 and above).

Don’t want to complete on-line?  No problem!  You can click on the “Printable Application” button below to have the option of downloading the application to complete by hand.  Your handwritten application can be provided as follows:

  • Attach to your e-mail and send  to:


  • Mail to:  Region V Systems, c/o Host Homes Program, 1645 N St., Lincoln, NE 68508.

Next steps in the application process:

  • You will receive e-mail confirmation that your application was received.
  • Your application will be assessed to ensure you are able to meet the minimum requirements to become a Host Home Provider.
  • If you meet the minimum requirements, you will be contacted to schedule an interview and complete a home inspection.
  • Once the home inspection and interview has been completed, we will conduct a background check on everyone 19 or older in the household.  Thereafter, you will be contacted regarding our feasibility to move forward with your application.
  • The last step is to schedule a 6-hour orientation session, which is required to become a Host Home Provider.
  • You will be matched with a young adult as soon as possible.

If, at any time during this application process it is determined that you do not meet the current needs of the Host Homes Program, you will be notified in writing.

Questions? E-mail or call Dani DeVries at 402-441-4351. 

Thank you for your interest, and we look forward to receiving your application!

This application is for Host Home Providers only. If you are a young adult experiencing homelessness, please contact  Dani DeVries at (402) 441-4351 or at

Please note the application does not save if you close the browser before you submit the application — you will lose your work!  Please gather information about your previous employment, addresses, and phone numbers ahead of time to prepare for the application process.

  • This application should be filled out by the person/s listed above. If there is more than one person this would be the co-applicant.
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  • Please list all children and other adults living in your home.

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  • Please list your employment for the past 5 years, starting with your current job.

  • Co-Applicant

  • Below, please provide information about yourself, your family and community, some of your life's experiences, etc. Write it with the young person in mind as a reader. The purpose of this information is for the young person to get to know you a bit, find out why you want to be a host, and to see if you might be someone that would be a good match for them.
  • 3) Do you have any reservations hosting young adults who may:
  • List two references whom you have known at least 1 year and one reference whom you have known for 5 years. These references should not be related to you. If you are applying with another person, your references should know both of you and how you function as a family.
  • Region V Systems is prohibited from contracting with an individual for paid services who is on the federal Office of Inspector General’s “List of Excluded Individuals and Entities” (LEIE) database. As an applicant associated with Region V Systems’ federal Host Homes Program, this is to inform you that your Social Security Number(s) (as provided with this application) will be used to verify that your name(s) is(are) not on the LEIE database.

    Region V Systems’ ability to contract for your services/payment for services will be delayed and/or denied if your name(s) is(are) documented in the LEIE database.

    If you have questions or concerns about this information, please contact Region V Systems’ Corporate Compliance Officer, Kim Michael, at or call 402-441-4350. You may view the federal Office of Inspector General’s public website used for LEIE verification at:

    I hereby certify that the information contained in the Region V Systems Host Homes Program Application is true and complete to the best of my knowledge.

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  • This field is for validation purposes and should be left unchanged.