GUARDIANSHIP ASSISTANCE PROGRAM

GUARDIANSHIP ASSISTANCE PROGRAM
Meals on Wheels Social Services Division

644 Linn Street, Suite 304, Cincinnati, OH 45203 (513)559-4488
GUARDIAN APPLICATION
Name
Street
City
Zip Code
Home Phone
Work Phone
Cell Phone
Fax
E Mail
example@example.com
Birthdate

MonthDayYear
Date
Last 4 of Social Security #
Highest Grade of Schooling Completed
Occupation
EMERGENCY CONTACTS
1. Name
Relationship
Home Phone
Cell Phone
Work Phone
2. Name
Relationship
Home Phone
Cell Phone
Work Phone
EMPLOYMENT HISTORY (list Employer, Position, Dates)
1.
2.
3.
VOLUNTEER POSITIONS (list Organization, Position, Dates)
1.
2.
3.
How did you learn about the Guardianship Assistance Program?
Why do you want to serve as a Guardian for an older adult with a mental impairment?
Do you have access to reliable transportation? If no, please explain

YesNo
If no, please explain
Detail any personal or professional experience you have working with older adults or agencies serving them
Have you ever served as a Guardian? If so, in what state/county?
Have you ever been charged or convicted of any crime involving theft, physical violence, sexual, alcohol or substance abuse, and, if you have been so charged, please list the date and place of each charge and each conviction. (If none, please state NONE).
PERSONAL REFERENCES
These individuals should be people who can vouch for your character. They must have known you for at least one year. You may use a relative as a Reference, but only as one of your References. If you are employed, one Reference should be from your employer or a co-worker. Please inform these people that they are being used as a Reference and will be contacted by the Guardianship Assistance Program. Please give a complete name and address, including zip code, as we will be sending a Reference request letter
1. Name
Phone
Street
City/State
Zip Code
Relationship
Length of Time Known
2. Name
Phone
Street
City/State
Zip Code
Relationship
Length of Time Known
3. Name
Phone
Street
City/State
Zip Code
Relationship
Length of Time Known
4. Name
Phone
Street
City/State
Zip Code
Relationship
Length of Time Known
PLEASE READ CAREFULLY
All of my responses to the questions in this Application are true and I have no objection to having my References contacted or inquiries made to verify statements herein. The above information and any further information will be used in determining my suitability as a Guardian. A copy of this Application may be supplied to the Hamilton County Probate Court if requested. Otherwise, all information will be confidential. My signature on this Application does not commit me to serving as a Guardian at this time, but is completed as a statement of my interest and intent. All individuals will be considered regardless of race, religion, national origin, sex, or marital status.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

GUARDIANSHIP ASSISTANCE PROGRAM

GUARDIAN APPLICATION

EMERGENCY CONTACTS

EMPLOYMENT HISTORY (list Employer, Position, Dates)

VOLUNTEER POSITIONS (list Organization, Position, Dates)

PERSONAL REFERENCES

PLEASE READ CAREFULLY