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Richmond Society for Community Living > Surveys  > New Survey

New Survey: HomeShare-OvernightRespite-Application

Date of Application
First Name *
Last Name *
Home Phone
Cell Phone
Postal Code
Are you interested in being a Home Share Caregiver (where an individual lives with you in your home) or a Respite Caregiver (where you provide respite care overnight)?
Are you currently employed?
Present Employment Job Title
Name of Employer
May we contact your present employer if necessary?
Supervisor Name and Phone Number
List all the people who live in your home (i.e. spouse, children, borders) Please include relationship to you and their ages.
What languages do you speak?
Do you have a valid BC Driver's License?
Do you own a vehicle?
Type of support you are willing/able to provide. Select all that apply.
Level of care you feel comfortable supporting:
  Mild Moderate Severe
Behavioural/Multiple Challenges 
Experience level with personal care
  Low Average High 
Giving Medication 
Assistance with Feeding 
Have you ever provided care to someone other than a family member?
If yes, explain
Information About Your Home
  Yes No N/A
Can the Coordinator come do a Safety Visit? 
Are all household members in good health? 
Does anyone living in the home smoke? 
Do you have pets? 
Do you have smoke detectors? 
Is your home wheelchair accessible? 
Do you have a fenced backyard? 
Any additional comments or information you would like to share with us?
I declare that the information contained in this application is true to the best of my knowledge and believe that I have not omitted information requested.