HomeShare PROVIDER Application

HomeShare Provider Application
Dear applicant,

Thank you for your interest in ElderHelp’s HomeShare Program. The purpose of the program is to match people looking for a housemate with individuals seeking affordable housing. It is an opportunity to lower your housing costs while remaining independent at home.

Before you decide to start the enrollment process, please take a look at the “Eligibility Criteria for HomeShare Provider Applicants.” If you decide to enroll in the program, please read the “Home Provider Information” thoroughly, and complete this Home Share Provider Application.

Upon receipt of the application, a HomeShare coordinator will call you to schedule a one (1) hour personal interview at your home.

After you have reviewed the enclosed material, should you have any questions or comments, please contact the nearest HomeShare office.

San Diego: 619-284-9281

Poway or Vista: 858-748-9675

Sincerely,

The HomeShare Team

Step 1: Check Your Eligibility
Personal Requirements

- You are able to provide for your own personal care, or have other help in place to
assist you with your personal care needs. You are able to transfer on your own if you use a wheelchair. You do not need assistance during the night, except in a case of an emergency. You do not need 24-hour care and/or supervision. You can advocate for yourself and communicate openly and clearly.

Residency Requirements
- You reside in the city of San Diego (in a 921… zip code), or in the cities of Poway, La Jolla, or Vista.
- Your home must be safe and clean.

Sharing your Home
- You must have private bedrooms for you and your housemate(s), as well as, a private or shared bathroom inside your home.
- You must be willing to share the common areas of your home, including kitchen privileges.

Income Requirements
- You will be asked what the amount and source of your monthly income is.
*Note: Income verification is purely for statistical purposes only.

Health Screening Requirements
- A signed release giving ElderHelp permission to send a questionnaire to your healthcare provider, or providers, is required.

Other Requirements
- Three (3) personal references who have known you at least five (5) years and with whom you have regular contact. References may not be family members, significant others, or life partners. -Must agree to complete a background check.

Step 2: Personal Information
Full Name*

First NameLast Name
Date

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Date of Birth. Must be 18 years or older.*

MonthDayYear
Date
Age:*
Email
example@example.com
Where did you learn about the HomeShare Program?*
Have you applied for, or been enrolled in, the HomeShare Program before?*
Please check the box below if you have others living with you:

Yes, others are living with me
Please list name(s), gender, age(s) of additional person(s)*
Will this person continue to live with you?*
Are you willing to share a home with someone who has children living with them?*
What is your preferred language?*
Do you speak any other languages? If so, please list here:
What is your gender?*
What gender roommate are you seeking to live with?*
Please check the box below if you are currently vaccinated:

Yes, I am vaccinated
Are you willing to live with someone who is unvaccinated?*
Please select your race/national origin:*
Please select your ethnicity:*
Are you a Veteran or Veteran Spouse?*
Have you ever been convicted of a felony?*
Please explain the circumstances surrounding your felony:*
Please select all of the following that are applicable to you (can select multiple):*
Please share any relevant information regarding the above conditions. We would like to have a better picture of your mental and physical health so that we can determine your eligibility for our program.*
Have you had any injuries, falls, or hospitalizations within the last year?*
Please provide a brief description of the circumstances (including how often you have been to the hospital in the past year):*
Do you currently need assistance with any ADLs? (bathing, dressing, taking medications, eating, toileting, transferring, etc.)*
Is anyone assisting you with any of the activities listed above?*
Please explain:*
Are you currently being treat by a physician, psychiatrist, or therapist?*
Please explain:*
Emergency Contact*

Step 3: Housing History and Preferences
Which type of HomeShare match are you interested in? (please select one)*
Please select all of the types of services that you would consider receiving (can select multiple):*
How many hours of service would you be looking to receive per week?*
# hours per week
What type of home do you live in?*
Please check the box below if you own your home:

Yes, I own my home
Will your landlord allow you to take in a housemate?*
Are you offering a private bedroom?*
Please check the box below if your home has stairs in it:

Yes, my home has stairs in it
What type of bathroom are you offering?*
What date will the room be available?*

MonthDayYear
Date
Do you smoke?*
Please check the box below if you are willing to live with a smoker:

Willing to Live With a Smoker
Do you have a history of drug or alcohol abuse?*
How long have you been clean and sober?*
Can anyone attest to your sobriety?*
Do you have pets?*

YesNo
Please provide details about pet (type, size, number of pets, name, etc.):*
Please check the box below if you are willing to live with pets:

Willing to Live With Pets
State any other relevant information you would like our HomeShare team to know and consider:*

Step 4: Financial Information
What are your sources of income? Select all that apply*
What is your ANNUAL income? (For demographic purposes)*
Do you have a Conservator or Power of Attorney handling your affairs?*
May we contact the individual on your behalf?*
Conservator/POA Name and Phone Number:*
How much are you looking to receive for rent each month? (Cannot be more than $1200)*
Are utilities included in the rental price?*
Receipt of ElderHelp HomeShare Program Information
By signing below, you consent to the following statement:

I have received the Home Provider Information Packet outlining the current HomeShare Program policies. I have either read it, or had it read to me carefully. I agree that I will maintain and abide by all HomeShare policies while participating in the HomeShare Program. I understand that this document has been prepared for the information/guidance of all HomeShare participants. It is intended to cover the policies and conduct most often applied to HomeShare activities. I accept that, with time, the information will change as these policies are under constant review. I understand that I will be notified in writing of any such changes.
Signature*

Clear
Date

MonthDayYear
Date
HS Coordinator Email Notification

rstrickland@elderhelpofsandiego.orgelandsman@elderhelpofsandiego.orgvolunteer6@elderhelpofsandiego.orgCMorris@elderhelpofsandiego.org
Company

Home Provider
Should be Empty:

HomeShare Provider Application