Host Family Application

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

	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?

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

Yes, all go to daycare, preschool or schoolSome go to school and some are still at homeNo, all are young enough to stay at homeNo, my kids are homeschooledN/A
HOME DESCRIPTION
Do you live in a house or an apartment?

HouseApartment
Will the child/guardian have their own room?

Yes, own room on shared floorYes, own room on own floorYes, entirely separate spaceNo, shared room
Will the child/guardian have their own bathroom?

Yes, the bathroom is within their room or separate spaceYes, they will have their own bathroom but it is outside of the room or separate space.No, they will have to share their bathroom.
Where will the child’s room be located?

First floorSecond floorOther
Are there stairs in your home?

YesNo
Do you have a swimming pool?

YesNo
Are you in a gated community?

YesNo
Do you live on a busy street?

YesNo
PLEASE ANSWER THE FOLLOWING QUESTIONS
Do you drive and have a car?

Yes, I have multiple carsYes, I have a car but it is shared with the familyNo, I do not have a car.
Are you flexible to help with driving the child to appointments, especially during weekdays?

Yes - I have a lot of flexibilityOccasionally - I work remotely or do not work and have flexibilityNo - I work in an office and do not have flexibility.
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?

YesNo
Any pet at home?

YesNo
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?

YesNo
Can you host a child outside of your religion?

YesNo
Have you hosted a child before?

YesNo
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?

Less than 1 month1 to 2 months3 to 4 months5 to 6 monthsMore
Are there any age restrictions?

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

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

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

YesNo
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?

YesNo
Gender preference:

MaleFemaleDoesn't matter
Are you employed full time or part time?

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

YesNo
Should be Empty:

Host Family Application

HOME DESCRIPTION

PLEASE ANSWER THE FOLLOWING QUESTIONS