Volunteer Application to Stay in a Host Home
Name:
Your answer
Address:
Your answer
City:
Your answer
State:
Your answer
Zip:
Your answer
Phone:
Your answer
E-mail address:
Your answer
Are you coming to the warehouse as part of a larger group?
Name of Group:
Your answer
Number in family/unit that need housing:
Your answer
Limit is five unless air mattresses can be used. (NOTE: Non-family members above age 12 need a roommate of the same gender to be housed. Name of person #1:
Your answer
Age of person #1:
Your answer
Gender of person #1:
Relationship of person #1 to applicant:
Your answer
Name of person #2:
Your answer
Age of person #2:
Your answer
Gender of person #2:
Relationship of person #2 to applicant:
Your answer
Name of person #3:
Your answer
Age of person #3:
Your answer
Gender of person #3:
Relationship of person #3 to applicant:
Your answer
Name of person #4:
Your answer
Age of person #4:
Your answer
Gender of person #4:
Relationship of person #4 to applicant:
Your answer
Name of person #5:
Your answer
Age of person #5:
Your answer
Gender of person #5:
Relationship of person #5 to applicant:
Your answer
Dates: Day of arrival at host home:
MM
/
DD
/
YYYY
Day of departure from host home:
Your answer
Define any medical needs such as first floor needed, allergy to pets, or other:
Your answer
Are there any other details you need to share with us to help us match you to a host home?
Your answer
Emergency contact for your stay in PA: Name and phone
Your answer
By entering your INITIALS and the DATE below, you are effectively providing your signature indicating that all the information on this form is true and accurate to the best of your knowledge.
Your answer
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