Ukraine Host Form

Name

Email Address

Phone

Address

Languages Spoken

Gender

Type of unit Type of unitFurnished RoomApartment in buildingBasement ApartmentTownhouseSeparate unit in main houseOther:

Host's Status Host's StatusOwner of unitTenant of unitOther

Rooms Available Rooms AvailableOneTwoThreeMore

Bathrooms Available Bathrooms AvailableOneTwoThreeMore

Entrance EntranceSharedSeparate

Meals MealsIncludedNot IncludedPartially Included

Hosting Term Hosting TermOne MonthThree MonthsSix MonthsOther

How many family members live at home How many family members live at homeOneTwoThreeFourMore than four

Are you willing to have a home visit by CCI Are you willing to have a home visit by CCIYesNo

Are you willing to obtain a Vulnerable Sector Check (Required for host matching program) Are you willing to obtain a Vulnerable Sector Check (Required for host matching program)YesNo

Additional Comments