HCW HOSTED Registration of Interest
Welcome to HCW HOSTED!

Thank you for your service on the front lines of the COVID-19 pandemic. Now it’s our turn to serve you.

Please fill out the following survey so that we can match you with available housing. After you submit this survey, a HOSTED coordinator will call you in 1-2 business days.

Please note: we currently only have housing available in Tucson, AZ.
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Part 1: Contact info
First Name *
Last Name *
Mobile Phone number *
Preferred contact method *
What is the best time of day to reach to reach you? *
Would you like to be contacted in Spanish? *
Part 2: Work Information
What is the name of your primary employer *
Name/Location of your primary work site
What is your job title *
Part 3: Current Health Status Related to COVID-19
In the past 14 days, have you experienced any symptoms of COVID-19? *
Do you have any of the following conditions? (check all that apply) *
Part 4: You and Your Household
In what year were you born?
Zip code of permanent residence
What town are you currently residing in? *
In your permanent residence, do you live with children?
Clear selection
In your permanent residence, do you live with someone with any of the following conditions? (check all that apply)
Clear selection
Name and phone number of an emergency contact we may reach out to (in an emergency)
Name of emergency contact *
What is your relationship to the emergency contact? *
Phone of emergency contact: *
Questions and comments
Clear form
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