Host Family Application Form

HOST FAMILY APPLICATION FORM
Introduction

HEAL Palestine is a U.S. registered nonpolitical, nonprofit humanitarian organization working to provide every young Palestinian in Gaza a chance for a brighter future through Health, Education, Aid, and Leadership. We are seeking compassionate and responsible volunteers to host injured children from Gaza, along with their accompanying family members, in their homes during treatment in the U.S. Your participation is crucial in providing a supportive and nurturing environment for these children as they receive medical care.
Instructions

Please fill out the form with accurate and complete information. All information provided will be kept confidential and used solely for the purpose of assessing your suitability as a host volunteer. Compliance with HEAL Palestine's child protection guidelines and protocols, which will be provided to volunteers, is mandatory.

Personal Information
Primary Host (who will be primarily responsible for the child):*

First NameLast Name
Phone/WhatsApp Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation*
Home Address*

Street Address

Apt. No.

CityState / Province

Postal / Zip CodeCountry
Secondary Adult Contact living in the home:*

First NameLast Name
Phone/WhatsApp Number *
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation*
Please list all other adults and/or children who live in the house. Please provide the age, gender, and occupation of each family member. *
How long are you able to host a child and their companion(s)?
Are there dates that you cannot host?*
If yes, when?
Housing Information
Are you willing to host the child along with their mother, and any other companion?*
Is there a specific child you would like to host? Please provide more information:
Type of Accommodation*
Please describe the living arrangements for the family including room(s) and bathroom(s) that are available for them as well as the surrounding community:*
Does your home have any special accommodations available (e.g., wheelchair accessibility, medical equipment, ramps)?*
Do you have any pets? (If yes, please provide details):
Does your family speak Arabic?*
Does anyone in your household smoke?
Are there any firearms in the household? If yes, how are they stored?*
Please upload a valid driver license of anyone who will be driving the child and the companion.

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Experience and Background
Have you hosted a sick or injured child before? Please explain. *
Briefly explain why you are interested in hosting a sick or injured child for medical care.*
Have you or anyone in your household ever been convicted of a crime?*
Have you or any household member ever been investigated or reported for child abuse or neglect?*
If yes, please explain:
Please provide the names, contact numbers, email addresses, and the relationship of two references: *

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship
Reference two:*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship

Child Protection Guidelines and Protocols:
Do you agree to comply with all HEAL Palestine child protection guidelines and protocols?*

YesNo
Are you willing to undergo a background check?*

YesNo
Do you agree to attend a mandatory training session on child protection and hosting guidelines provided by HEAL Palestine?*

YesNo
Additional Information:
Do you have any questions regarding hosting the child and their companion? Or do you have any additional comments to share?
Consent and Signature: By submitting this application, I confirm that all information provided is accurate to the best of my knowledge. I understand that completing this form does not guarantee acceptance as a host family, and I agree to participate in any required interviews as part of the selection process. Further, I consent to HEAL Palestine performing background checks on all adults in the household.*

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Print Name of Signatory:*

First NameLast Name
If you have any questions, please contact

Randa Eldarini at randa.eldarini@healpalestine.org
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HOST FAMILY APPLICATION FORM

Introduction

Instructions

Personal Information

Housing Information

Experience and Background

Child Protection Guidelines and Protocols:

Additional Information: