HomeShare Provider Application

HomeShare Provider Application

Please complete the following with as much detail as possible to speed up your application process.
Your Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Education and Experience
Please select your highest level of education*

Highschool (GDP completion)CollegeUniversity degreeMasters degree or higher
Please list any special training have you completed (eg. sign language)*
Do you have a current First Aid + CPR Certificate?*
Expiry Date

MonthDayYear
Have you ever provided HomeShare support in your home?*

YesNo
If yes, where and when did you provide HomeShare Support?
Have you ever applied to be a foster parent?*

YesNo
If yes, where and when?
Please list all the languages you speak
Please list any additional training, work experience, or knowledge that might assist you as a HomeShare Provider*
2. Employment History
What is your current occupation?*
Name of employer/organization?*
Supervisor's Name*
First and last name
Supervisor's Phone*
Please enter a valid phone number.
May we contact your current employer (if necessary?)*

YesNo
3. Tell us about yourself and your home life
Please tell us who lives in your home with you (eg. spouse/partner, children, borders, pets, etc). Include first and last name, birthdate, age, and relationship for each person in your home. *
List all previous services you or any member of your family has received from the Ministry for Children & Families, Community Living B.C, Vancouver Coastal Health Authority and/or the Ministry of Housing and Social Development. Include any additional assistance from Family Services, Protection Services, Employment Services or any form of income assistance. *
Do you have a valid B.C. Driver's Lisence?*
Please select the most correct statement*

I own my own vehicleI have a vehicle regularly available to meOther
Can a coordinator come to your home for a home safety visit?*

YesNoN/A
Are all family and household members in good health?*

YesNoN/A
Do you smoke? (includes tobacco, cannabis, and vaping)*

YesNoN/A
Does anyone residing in your home smoke?*

YesNoN/A
Do you have any pets?*

YesNo
If yes, please list all of your pets
Do you have smoke detectors?*

YesNoN/A
Is your home wheelchair accessible?*

YesNoN/A
Do you have a backyard?*

YesNoN/A
Is your backyard fully fenced?*

YesNo
Are you willing to relocate to the individual's home? (if applying to be a roommate)*

YesNo
How many years have you lived in your current home?*
How many years did you live in your previous home?*
Please describe your home and neighbourhood/community activities close by*
If an individual is placed in your home, what is your proposed sleeping arrangement?*
4. Let's find out what kind of support you can offer
Please indicate the level of commitment you can offer (you may select more than one)*

HourlyWeekendsLong weekendsUp to 1 weekUp to 3 weeksSeasonalHolidaysEmergencyOvernights
Where can you offer support to individuals? (you may select more than one)*

In your homeIn individual's home
What level of support do you feel best suited for? Please also select the severity*

MentalPhysicalBehaviouralMulti-handicapped
MildMildMildMildModerateModerateModerateModerateSevereSevereSevereSevere
Please use the space below for any additional information or comments*
TERMS and CONDITIONS for HomeShare Providers

As part of our screening and assessment process, the following mandatory items must be completed prior to providing support:
- Must be of legal age (19 years or older)
- Physician's assessment form
- Valid Work Safe B.C. approved Emergency First Aid + CPR
- Satisfactory Driver's Abstract - ICBC Driver's Public Search
- Satisfactory Criminal Record Review Program (CRRP) - for working with children and/or vulnerable adults
- Anyone living in your home who is 19 years or older will also be required to complete a CRRP
- MCF Prior contact check
- Three references (not a relative) - must be at least one employer/two character references that have known you for at least two years
- Initial Health and Safety Visit completed (if applying to be a HomeShare Provider in your home)
- Valid home/tenant insurance
- Registration with Work Safe B.C. POP insurance
- Review of HomeShare Provider's handbook
- Completed HomeShare contract
Do any of the above conditions pose a problem for you? If so, please explain.
Do you have any comments or questions?
I DECLARE THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE, AND I BELIEVE THAT I HAVE NOT OMITTED INFORMATION REQUESTED.
Please sign and date

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Date

MonthDayYear
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HomeShare Provider Application

1. Education and Experience

2. Employment History

3. Tell us about yourself and your home life

4. Let's find out what kind of support you can offer

TERMS and CONDITIONS for HomeShare Providers