Householder Application Form
Homeshare Scotland
Contact Details
Householders Name
*
First Name
Last Name
Is the householder named above the main contact?
Yes
No
Householder Landline Number
e.g. 0131 234 5678
Householder Mobile Phone Number
e.g. 07123 456789
Householder E-mail
example@example.com
Contact name (who is filling out this form)
*
First Name
Last Name
Contact E-mail
*
example@example.com
Contact Phone No.
*
e.g. 07123 456789
Relationship to the Householder (optional)
Do you have Power of Attorney?
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Householder Details
Householder Address
*
Street Address
Street Address Line 2
Town/City
Council Area (Optional)
Postal / Zip Code
Householder Gender
*
Male
Female
Other
Householder Age
*
Nationality
Spoken Languages
Relationship Status
Do you smoke?
*
Yes
No
Do you have any pets? If so please describe.
*
Do you have any physical or medical conditions that you feel we should be aware of?
(e.g. do you use a walking stick to walk, is eyesight impaired,
Do you currently receive any other services (e.g. Social workers / Carers etc)
Tell us a bit about yourself, your lifestyle, hobbies and interests :
e.g. Where you grew up, what are your hobbies and interests etc.
Help & support requirements
Tick the box below to acknowledge that Homeshare Scotland does not provide care services. Any homesharer that is matched with a householder will have no caring responsibilities in a medical/health context.
*
I understand that there is no caring role expected of the housesharer
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Your Preferences for a Sharer
From what date would you like a Sharer to move in?
*
-
Day
-
Month
Year
Date
Would you be happy to live with a :
Male
Female
Couple
Is this a non-negotiable?
*
No, I'd be willing to re-consider based on compatibility.
Yes, this is a non-negotiable for me.
Preferred Language
Would you live with someone who has a pet
Yes
No
Would you share with someone who smokes?
Yes
No
Outside Only
What sort of person do you think you might like to share your home with?
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About your property
Do you live in a flat or house?
Number of bedrooms in property
Does the available room have an ensuite (or it's own bathroom)?
Is the room a Single / Double / Twin bed?
Please include a brief description of the property
What facilities will the sharer have access to?
Wifi
Televison
Washing machine
Free parking nearby
Secure bicycle storage
Please upload some photos of the rooms in your home that you are happy to share.
Browse Files
Drag and drop files here
Choose a file
Bedroom, kitchen, living space, bathroom, garden & back of house if applicable.
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How did you hear about us?
Please Select
Newspaper / Magazine
Internet
Flyer
Poster
Someone told me about Homeshare
Other
Please Specify
We are always trying to improve our service. How happy were you with the questions on this form?
1
2
3
4
5
Do you have any questions or suggestions as to what we could do better?
Finally, may we add you to our mailing list to keep you updated on Homeshare news? (Opt out any time)
Yes
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