Become a Home Share Provider Please enable JavaScript in your browser to complete this form.Full legal name *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHome Phone numberCell phone numberEmail *Education level achievedUniversityHigh SchoolThird ChoiceCurrent employerPosition Length of employment Languages spokenDriver’s license Access to a reliable vehicle? *YesNoHave you and/or persons living in your home; ever committed, been arrested for, been charged with or convicted of any criminal offense? *YesNocriminal offense detailHave you provided home sharing, foster care, or respite support before? If yes, with what organization and to what capacity? What special training do you have? Are you currently supporting an individual with a developmental disability in your home? *YesNo List those who currently live within the home. Provide details about the relationship to the primary applicant and their birth dates. Resident 1NameRelationship to primary applicantsYear of birthEducationCurrent occupationWill this person provide care to the supported individual *YesNoResident 2NameRelationship to primary applicantsYear of birthEducationCurrent occupationWill this person provide care to the supported individual *YesNoHousehold’s normal weekend routine Applicants regular schedule, commitments and priorities. Example; school, work, childcare, regular activities. Section 2 – Tell us about your home and living situation Do you own or rent? *OwnRentHow long have you been living at the home?What type of home is it? *Select an optionHouseCondoApartmentTownhouseDetachedOther home otherWhat type of living space do you have available to support the individual?Separate suiteMaster bedroomBedroomOthertype of space - otherIs there access to the back yard? *YesNoDo you have any pets? *YesNoWhat typeSection 3: Decision to Provide Home SharingWhat do you know about providing home sharing for adults with a developmental disability?Will others be impacted by this decision (children, partner, others living in the home)? If so, have they been consulted and areWhy are you considering home sharing at this time?How long are you able to commit to providing this type of support?Section 4: Work HistoryBriefly outline your work historyBriefly outline your work history 2Briefly outline your work history 3Briefly outline your work history 4Section 5 :Type of support you are able to provide Check all that applyaddictionmobility/physical disabilityaggressive behaviorpersonal careanxietyprofanityaugmentative communicationseizures/epilepsyblinddeafself-injuriousdementiasexualitydiabetesstealing/theftdiet managementsuicidaldisrupted sleepwandering/running awayincontinenceyellingmedicationfetal alcohol spectrum disorder (FASD)Comments Section 6 – Closing Any additional information you would like us to have or comments you would like to make?declaration *I declare, the application I am submitting is true and accurateSubmit
