Welcome to The Network/La Red! We appreciate your interest in volunteering. Volunteers are crucial to running a successful hotline, safe home, advocate, or outreach program. In order to assist us in getting a better idea of who you are, please answer the following to the best of your ability.

Please copy and paste into body of email or print out
and mail or fax (617-423-5651)

HOUSEHOLD INFORMATION

Household Address:  __________________________________________________

Household Phone number(s):  _______________________________________________

Please provide information about each household member:

1. Name:  ______________________________                   

Age:  _______________                       

Sex/Gender ID:  ___________________                      

Languages spoken:  ____________________________   

2. Name:  _________________________

Age:  ____________________________ 

Sex/Gender ID:  ___________________

Languages spoken:  __________________________________

3. Name:  _________________________

Age:  ____________________________ 

Sex/Gender ID:  ___________________

Languages spoken:  __________________________________

4. Name:  _________________________

Age:  ____________________________ 

Sex/Gender ID:  ___________________

Languages spoken:  __________________________________

5. Name:  _________________________

Age:  ____________________________ 

Sex/Gender ID:  ___________________

Languages spoken:  __________________________________

6. Name:  _________________________

Age:  ____________________________ 

Sex/Gender ID:  ___________________

Languages spoken:  __________________________________

 What is/are the relationship(s) between household members?

About how often does household composition change?

Does everyone in the household agree to providing a safe home for The Network/La Red?

If there are children in the household, how are they disciplined (i.e., time out, spanking, etc.)?

Do animals live in the household?  If so, what kind and how many?

Is the household wheelchair accessible?  Is there a TTY in the household?

What holidays are celebrated in the household?  How do you celebrate them?

Is smoking permitted in the household or on the premises (i.e., on the porch, etc.)?

How are food and meals dealt with in the household (i.e., do you buy food separately or together, are meals shared, etc.)?  Are there food restrictions in the household?  Would those restrictions apply to safe home guests (i.e., no meat in the house, keeping kosher, etc.)?

What kind of space is available to safe home guests (a separate room, a pull out sofa in the living room, etc.)?

Can you accommodate:

 ______ a single person                  ______pets (what kinds and how many?)  ________________

 ______ a person with _______ children        

A.  How many nights can safe home guests stay at a time?

_______ 1 night                                  _______ 4 nights

_______ 2 nights                                _______ 5 nights

_______ 3 nights                                 _______ more than 5 nights (please specify)

B.  How many times a year can you provide shelter?  _____________________________

C.  How often can you provide shelter?

_______ once a month                 _______ once every 4 months

_______ once every 2 months    _______ once every 5 months

_______ once every 3 months    _______ twice a year

If you can shelter children, do you have:

_______ toys (please specify for what ages) ___________

_______ crib                                                      _______ safety gates

_______ play space                                           _______ window bars

_______ high chair                                            _____ outlet covers   

_______ other safety items(please specify)

 Would you be willing to use these items if provided by The Network/La Red?

At what times do household members go to work, school, etc. C i.e., what hours are folks generally home, and when is the household generally empty?

Would safe home guests be able to be in the house when no one is there?

Would it be possible for Network staff to meet with guests in your home?

What hours would you be available to be called about the possibility of sheltering someone or to check in about how a safe home stay is going?  Is there a primary contact person or an order in which we should try to reach household members?

A.  Is the household near public transportation?  If so, how far away, and which bus/T stop? 

B.  Are you able to help with transportation for guests to or from your home?

The Network has set rules about mealtimes, curfew, phone use, and the possession of keys.

• Curfew is 9pm on weeknights and 10pm on weekends.
• The safe home provider is expected to invite guests to share in mealtimes (you will be compensated for the cost of guests' meals), however if they prefer to eat at another time or eat their own food, we expect that they will be able to do so.
• Guests are expected to be able to make necessary local phone calls.  The Network can provide them with a pre-paid phone card to make long distance calls, and they are not to make collect calls from your phone.
• Guests are allowed to have a set of keys for which the will sign an agreement not to duplicate and which they will return at the end of their stay.

These rules are explained to each safe home guest.  The following questions let us know how comfortable you are with these rules, and to what extent you could tailor these rules to the needs of each guest.

Could guests use your kitchen when you're not there?

Would you prefer that guests not have a set of keys?

Would you be comfortable with a later curfew or no curfew?  If so, what time?

Could guests use your phone for necessary long-distance calls?

SAFE HOME PROVIDER APPLICATION

HOUSEHOLD MEMBER QUESTIONNAIRE

EACH HOUSEHOLD MEMBER SHOULD FILL OUT A SEPARATE FORM

Name:  _____________________________________________________________

Address:  ___________________________________________________________

Phone #(s):  _________________________________________________________

How did you hear about the Network?  How did you hear about the opportunity to provide a safe home?

What made you decide to provide a safe home?

A.  How often do you have guests at the house?  Would it be possible for you to not have guests while providing shelter?  If you have a regular guest (i.e., a close friend, partner, family member, etc.), would they be willing to go through the safe home training process?  (If so, please let us know so we can give them one of these forms to fill out.)

B.  To protect your own safety and that of your safe home guests, we ask that you keep confidential and not tell anyone that you provide a safe home for the Network.  (You can say that you volunteer for the Network, just not detail exactly what you do.)  Will this be possible?  Please describe anything that would make this difficult.

A.  What is your experience with domestic violence, whether personal, through work or volunteer experience, etc?

B.  Have you ever done anything you or someone else considered to be abusive?  Please explain.

 How would you define battering?

Why do you think battering happens?

Please list/describe any crisis intervention experience you have (whether personally, through work or volunteer experience, etc.)

While most of us experience some form of oppression, many of us also hold some privilege, whether class, race, religion, language, ability, age, gender identity, etc.  Have you dealt with situations where someone has confronted you about privilege you hold or oppressive comments/actions you have done?  Please describe what kinds of issues have come up for you, and how you have dealt with them?

Do you have concerns about providing a safe home?  Please list/explain.

What areas do you feel you need the most training in?

Please list two references, personal or work-related.

1.  Name:  ________________________________ 

Phone #(s):  __________________

Address:  _____________________________________________________

Relationship:  ________________________ 
How long known?  ________________

2.  Name:  ________________________________ 

Phone #(s):  __________________

Address:  _____________________________________________________

Relationship:  ________________________ 
How long known?  ________________

Comments or Questions?

You can call the Network office line 617-695-0877
Please mail back to:
The Network/La Red
PO Box 6011
Boston, MA 02114 or Fax: 617-423-5651 or email safehome@thenetworklared.org