Host Family Application Form

Host Family Application Form
Thanks for your support.

We are no longer accepting applications for Host Family

For any future Host Family considerations please fill out the form and we will reach out to you
- Primary Host Family:
- Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  MM-DD-YYYY
- Occupation*
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- *
  
  HomeWorkCell
- Email*
  example@example.com
- Home Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Type of Home*
  
  Detached HomeApartmentOther
- Household Members (List all)*
  Name, Age, Relationship
- Secondary Host Family (if applicable):
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  MM-DD-YYYY
- Occupation
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Type a question
  
  HomeWorkCell
- Email
  example@example.com
- 1. Patient Preferences
- Gender*
  
  MaleFemaleNo PreferenceOther
- Age Group*
  
  ChildTeenAdult
- 2. Hosting Availability:
- Start Date*
  
  MonthDayYear
  MM-DD-YYYY
- End Date*
  
  MonthDayYear
  MM-DD-YYYY
- Are you open to extending your hosting period?*
  
  YesNo
- 3. Special Considerations:
- Can you accommodate dietary restrictions?*
  
  YesNo
- Are you comfortable with cultural or religious practices?*
  
  YesNo
- Other Preferences*
- 1. Provide Shelter and Safety:
  - Offer a safe, clean, and stable living environment for the patient and their companion (if applicable), free of charge.
  - Ensure the patient feels secure and supported during their stay.
  2. Transportation Assistance:
  - Take patients and companions to and from all medical appointments as per their treatment schedules.
  - Assist with essential errands, such as trips to the grocery store or pharmacy.
  - Take the patient or companion to the bank to help them open a bank account.
  3. Daily Needs Support:
  - Help the patient meet basic needs, including meal preparation or grocery shopping, if they cannot do it themselves.
  - Ensure patients have access to hygiene products and any specific items related to their condition.
  4. Administrative Assistance:
  - Provide your address to help the patient register for services, such as healthcare, education for children (if applicable), and community programs.
  - Assist with completing forms, organizing documents, or accessing local resources like social services.
  5. Medical Support and Coordination:
  - Ensure the patient attends all scheduled appointments, follows medical care instructions, and adheres to the prescribed treatment plan.
  - Notify healthcare providers or case managers of any medical changes or challenges.
  - Stay informed about the patient’s care plan and provide updates to the organization managing the case.
  6. Cultural and Social Integration:
  - Support cultural acclimation, especially for non-English speakers, by providing resources or connecting them with local community groups.
  - Arabic-speaking hosts are preferred to help bridge language barriers for patients from Arabic-speaking backgrounds.
  7. Advocacy and Reporting:
  - Notify the sponsoring organization of any requirements or changes from your end that may impact the patient’s stay or care.
  - Report any emergencies, health concerns, or logistical challenges promptly.
  8. Bank and Financial Access:
  - Accompany the patient or their companion to the bank to help them open an account or manage financial tasks.
  Additional Information:
  - The duration of the patient’s stay may vary based on their medical treatment and recovery needs.
  - Hosts are encouraged to be flexible and understanding, as refugees often face significant challenges, including cultural differences, emotional trauma, or language barriers.
  - Please notify the organizing agency if any updates or new requirements arise during the hosting period.
- 1. I agree to provide:
  1. A safe and nurturing environment.
  2. Private or shared accommodations (with a same-gender household member).
  3. Meals and transportation to medical appointments.
  2. Emergency Protocols:
  1. I will contact the designated organization immediately in case of medical or other emergencies.
- 1.Background Check
- Have any household members been convicted of a crime?*
  
  YesNo
- *
  
  All household members 18+ must agree to a background check.
- 2. References: (Provide 2-3 personal or professional references)
- Reference #1*
- Reference #2*
- Reference #3
- I confirm that the information provided is accurate and agree to comply with all hosting guidelines and safety requirements.
- Date*
  
  MonthDayYear
  MM-DD-YYYY
- HUMAN CONCERN USA is a 501(C)3 Tax Exempt Nonprofit - EIN# 92-2388570
  www.humanconcernusa.org - info@humanconcernusa.org
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