Home Share: Application

Home Share: Application

*Available in alternate formats, upon request*
General Information
Name*

First NameLast Name
Pronouns
She/He/They
Birthdate*

MMDDYYYY
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Language(s) spoken*
Language
Language(s) spoken
Language
You are entitled to work in Canada by reason of:*

Canadian CitizenshipPermanent Resident StatusWork Permit
Proof of eligibility to work in Canada is a requirement of any position with Epic Opportunities and will be asked of any successful applicants.
Do you currently have a valid driver's license?*

YesNo
Do you have access to your own vehicle?*

YesNo
Is there a co-applicant for this form? (if yes, section can be found at the end)*

YesNo
Description of Home & Neighbourhood

List all individuals, other than yourself, who live in your home, including renters

Rows	Name	Age	Gender	Relationship
1.
2.
3.
4.
5.

Do you have any pets?*

YesNo
Number of people you would like to support in your home*

12
Gender, of person served, that would be best fit (choose all that apply)*

FemaleMaleNon-binaryNo preferenceOther
Age range, of person served, that would be the best fit (18+)*
e.g. 20-43
Age, of person served, that would be best fit (18+)*
Are you comfortable providing personal care? (i.e. bathing, oral hygiene, dressing, toileting, eating, etc.)*

YesNo
Are you comfortable providing emotional supports? (i.e. developing/maintaining relationships, teaching coping strategies)*

YesNo
Are you comfortable providing lifestyle supports? (i.e. meal planning/prep, budgeting, rec & leisure, household tasks)*

YesNo
Are you open to supporting someone who smokes?*

YesNo
Are you open to supporting someone who consumes alcohol?*

YesNo
Are you open to supporting someone who is sexually active?*

YesNo
Are you open to welcoming pets into your home?*

YesNo
Type of residence*

ApartmentCondoDuplexSingle familyTownhouseOther
Is your home accessible?*

YesNo
If yes, provide details*
(i.e. is there an elevator; ramp lifts; adequate floor space for a wheelchair; etc.)
Nearest bus routes
Nearby community resources
(i.e. rec centre, libraries, etc.)
Where in Winnipeg do you live?*
Find your city ward here
Education
High school attended*
Name
Country*
Did you attend a Post-Secondary Institution?*

YesNo
Post-Secondary Institution*
Name
Diploma/Degree achieved*
Title
Country*
Certification/Training
Emergency First Aid (or higher)*

YesNo
Non-Violent Crisis Intervention (NCI)*

YesNo
Orientation to Protection*

YesNo
Adults Living with an Intellectual Disability Act (ALIDA)*

YesNo
Do you have any additional certifications or training? List below
Work History - Past and Present

Work history*

Rows	Name of employer	Dates employed	Position held
1.
2.
3.

Do you currently provide respite or home share services for any programs or agencies?*

YesNo
If yes, provide details*
Have you provided home share services in the past?*

YesNo
If yes, provide details*
Availability (choose all that apply)*

DaytimeEveningsWeekends24 hours
If you are employed outside of the home, how many hours per week do you work?*

Less than 2020-3031-4041-5050+N/A
When are you available to start services?*

MMDDYYYY
I e.g. John Smith* , agree to the terms of the application process and confirm all information presented in this application form is accurate.
Date*

MMDDYYYY
I e.g. John Smith* , acknowledge, if chosen to move forward in the application process, I will be required to comply with Residential Care Licensing. This includes a Home Study Report which involves an in-depth review of an applicant's home and personal history prior to being offered a contract. Some topics covered are considered sensitive and may be difficult to address. All information disclosed is kept confidential in accordance to the Epic Opportunities Confidentiality Pledge.
Date*

MMDDYYYY
Co-applicant Section
Name*

First NameLast Name
Birthdate*

MMDDYYYY
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Language(s) spoken*
Language
Language(s) spoken
Language
You are entitled to work in Canada by reason of:*

Canadian CitizenshipPermanent Resident StatusWork Permit
Proof of eligibility to work in Canada is a requirement of any position with Epic Opportunities and will be asked of any successful applicants.
Do you currently have a valid driver's license?*

YesNo
Do you have access to your own vehicle?*

YesNo
Education
High school attended*
Name
Country*
Did you attend a Post-Secondary Institution?*

YesNo
Post-Secondary Institution*
Name
Diploma/Degree achieved*
Title
Country*
Certification/Training
First Aid*

YesNo
Non-Violent Crisis Intervention*

YesNo
Orientation to Protection*

YesNo
Adults Living with an Intellectual Disability Act (ALIDA)*

YesNo
Do you have any additional certifications or training? List below
Work History - Past and Present

Work history*

Rows	Name of employer	Dates employed	Position held
1.
2.
3.

Do you currently provide respite or Home Share services for any programs or agencies?*

YesNo
If yes, provide details*
Have you provided Home Share services in the past?*

YesNo
If yes, provide details*
Availability (choose all that apply)*

DaytimeEveningsWeekends24 hours
If you are employed outside of the home, how many hours per week do you work?*

Less than 2020-3031-4041-5050+N/A
When are you available to start services? *

MMDDYYYY
I e.g. John Smith* , agree to the terms of the application process and confirm all information presented in this application form is accurate.
Date*

MMDDYYYY
I e.g. John Smith* , acknowledge, if chosen to move forward in the application process, I will be required to comply with Residential Care Licensing. This includes a Home Study Report which involves an in-depth review of an applicant's home and personal history prior to being offered a contract. Some topics covered are considered sensitive and may be difficult to address. All information disclosed is kept confidential in accordance to the Epic Opportunities Confidentiality Pledge.
Date*

MMDDYYYY
Should be Empty:

Home Share: Application

General Information

Description of Home & Neighbourhood

Education

Certification/Training

Work History - Past and Present

Co-applicant Section

Education

Certification/Training

Work History - Past and Present