MOBS Home Stay  -  Host Intake Form

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.  

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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.   *
Do you agree  to provide at least 3 months room and food for the Ukrainians? *
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. *
Do you understand that no remuneration is provided *
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?
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Do you have any pets?
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If you have pets what type, and how many?
Are you willing to host any pets that might be coming with Ukrainian guests?
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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)
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Have you and all members of your household been fully vaccinated against COVID-19?
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Would you require that any person(s) you host be fully vaccinated against COVID-19?
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Do any members of your household smoke?
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Would you prefer to have non-smoking guests?
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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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