Host Family Application

Dear host family volunteer,

We appreciate your interest in volunteering to host a child who will be provided medical care in your area through the Palestine Children’s Relief Fund. We are a nonpolitical, nonprofit humanitarian organization and our objective is to do the best possible job that we can to serve the needs of our children who otherwise cannot get the treatment that they need locally. To better ensure that we place children in the appropriate environment, we have created this online survey and hope that you can complete it for us. All of this information is strictly confidential and will not be shared with anyone outside of the PCRF Treatment Abroad team and volunteer coordinator for this child.

Thank you for your cooperation and support.

Full Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

If United States, please choose:

Phone Number

Area CodePhone Number

E-mail

NAME AND AGES OF PERSON IN THE HOME

Rows	Name	Birth Date	Age	Relationship	Gender
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5

Do you have children at home?

If you have children, do they go to daycare/preschool/school?

Do you live in a house or an apartment?

Will the child/guardian have their own room?

Will the child/guardian have their own bathroom?

Where will the child’s room be located?

Other

Are there stairs in your home?

Do you have a swimming pool?

Are you in a gated community?

Do you live on a busy street?

Do you drive and have a car?

Are you flexible to help with driving the child to appointments, especially during weekdays?

If yes or occasionally, please elaborate on your flexibility in your day schedule and how long of a commute are you willing to make to get the child to his/her medical appointments?

Does someone in your household speak Arabic?

Any pet at home?

If yes, can you please describe the type and number of pets?

Are you familiar with the cultural and religious customs of the Middle East?

Can you host a child outside of your religion?

Have you hosted a child before?

If yes, please add some details, when, with which organization, a brief about your involvement:

How long would you be able to host a child?

Are there any age restrictions?

Would you be willing to host a female guardian with the child?

Are receptive are you to outside visitors, including members of the media or PCRF volunteers and board members?

Other

Are there children currently in your household receptive to sharing their parents especially with another child who requires a lot of attention?

How flexible is your day schedule and how long of a commute are you willing to make to get the child to his/her medical appointments?

Would you be willing to host a child with disability?

Gender preference:

Are you employed full time or part time?

Do you have any travel plans within the period of hosting?

Host Family Application

HOME DESCRIPTION

PLEASE ANSWER THE FOLLOWING QUESTIONS