MOBS Home Stay - Host Intake Form

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Thank you for your interest in hosting a Ukrainian Temporary Resident or family. This form is to gather information about you, your family, and your home in order to match you as closely as possible to a Ukrainian person or family.

Your Full Name *

Email *

Do you consent to a Criminal Record check and a Vulnerable Persons check for yourself and for any member of your household who is age is 18 or older. *

yes

Do you agree to provide at least 3 months room and food for the Ukrainians? *

yes

Do you consent to share information with the Ukrainian Canadian Congress (UCC), Ukrainian Diaspora Support Canada (UADSC), and any other organizations partnered with MOBS resettlement work. *

yes

Do you understand that no remuneration is provided *

yes

Physical Address *

Mailing Address (If different from above address)

Phone Number *

Cell Phone Number (If different from above)

Do you or any member of your household speak another language than English? If so what knowledge level would you classify as: Minimal, Moderate or Fluent. (Please note that Ukrainian or other language skills are not essential for hosting. This information is being requested to help us to better match you with a person or family.)

How many people currently live in your home?

Please provide the full name, gender, age and relationship to you of each person currently living in your home:

How many persons are you able/willing to host?

Are you willing/able to host children?

yes

Clear selection

Do you have any pets?

yes

Clear selection

If you have pets what type, and how many?

Are you willing to host any pets that might be coming with Ukrainian guests?

yes

Clear selection

If yes to pets - please describe your preference regarding what type and how many.

Are you able and willing to provide essential transportation for the family (for example, to appointments, job interviews)

yes

Clear selection

Have you and all members of your household been fully vaccinated against COVID-19?

yes

Clear selection

Would you require that any person(s) you host be fully vaccinated against COVID-19?

yes

Clear selection

Do any members of your household smoke?

yes

Clear selection

Would you prefer to have non-smoking guests?

yes

no prefence

Clear selection

Please provide any other details about yourself, your family, your home, or your preferences regarding guests, that you feel may be helpful to us.

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