Respite FamilyHome Application/Preference Form -

Name*

First Last

Email*

Why are you interested in FamilyHome/FamilyHome Respite?*

How did you hear about us?*

Facebook
Twitter
Instagram
Google
EAFWR Employee
Word of mouth
Other

If other, please specify:

Skills/Experience

Languages spoken and/or understood*

Skills/Experience/Courses Taken (please select all that apply)*

Other Skills

Interests*

Sports
Swimming
Animals
Outdoor Activities
Music
Computers/Technology
Community Connecting

Other Interests

Availability

Are you able to make a minimum one year commitment?*

Yes
No

Transportation*

Willing to Drive (access to vehicle with valid license and insurance)
Non-driver (for the purpose of employment)

Are you 18 years of age or older?*

Yes
No

Have you ever worked for our organization before?*

Yes
No

If yes, when did you leave?*

For providing support in your own home:

Program Interest*

FamilyHome Respite
FamilyHome

Are there any other people living at your address?*

Yes
No

If yes, please complete the following:

Name

First Last

Age

Relationship

Occupation

Name

First Last

Age

Relationship

Occupation

Name

First Last

Age

Relationship

Occupation

Name

First Last

Age

Relationship

Occupation

Name

First Last

Age

Relationship

Occupation

I understand that any persons in my home eighteen years of age or older, will be required to provide a completed vulnerable sector criminal reference check, if I will be providing support in my home. I agree:*

Yes
No

Please indicate your type of accommodation (i.e. apartment, townhouse, etc.)*

Is your house wheelchair accessible? (i.e. one level, ramps, etc.)*

Do you have space to accommodate an adult in your home? (If yes, please describe sleeping arrangement, etc.)*

Are you or anyone who lives in your house a smoker?*

Yes
No

Do you have Comprehensive Home Insurance?*

Yes
No

If yes, please provide the amount of liability coverage:

If matched with a family to provide support in my home, I would be willing to advise Extend-A-Family Waterloo Region with the name of my insurance carrier and policy number for my Comprehensive Home Insurance. I agree:*

Yes
No

Are you available to provide support for more than one person?*

Yes
No
Unsure at this time

Is there a particular person you would like to provide support for? Please indicate name:

I understand that if I am considered for an interview, I will be required to provide three completed reference forms (provided by Extend-A-Family Waterloo Region) and my completed vulnerable sector criminal reference check. I also declare that the information given above is true and that making a false statement on this form could result in termination of my support and/or termination of my employment. I agree:*

Yes
No

Is there anything else you'd like us to know about you?