RED DEER HOMESHARE

A MUTUALLY BENEFICIAL PROGRAM THAT HELPS TO BRIDGEGENERATIONS

STUDENT APPLICATION

Student Application

Application date: Legal Name: M FYear of Birth _____________

Address: City:

Postal Code:

Preferred neighbourhood 1st 2nd 3rd

http://www.reddeer.ca/City+Government/City+Services+and+Departments/Information+Technology+Services/Web+Map/default.htm

Email Address:

Telephone- Home: Cell:

What is the best way for us to contact you between 8:30am-5:00pm?

Is English your first language? YES NO

What other languages do you speak?

You currently live in Central Alberta Other area of Alberta Other Provi nce

Outside Canada Where?

Which school are you enrolled in?What program are you taking?Full-Time __ Part-Time ___

Do you usually study At home Away from home

Are you employed Full-Time Part-Time

N/ AIf you are not currently working, do you plan to secure employment while HomeSharing?

YES NO N/A

Updated May 1,2017

RED DEER HOMESHAREA MUTUALLY BENEFICIAL PROGRAM THAT HELPS TO BRIDGE GENERATIONS

You’re willing to offer a maximum of 10 hours a week of assistance with which of the following identified tasks in exchange for reduced living expenses (Please check all that apply)

Basic computer skills Minor home maintenanceCompanionship Pet careDriving Snow removalErrands Gardening/ yard workGarbage removal Watering plantsGrocery shopping Meal preparationHouse sitting Reaching, lifting, carryingHousework Other areas:LaundryMail collectionAppointment reminders

Do you have a preference to a type of dwelling?

House Fourplex Duplex Apartment Townhouse Condo Mobile N/A

What type of accommodation do you prefer?

One bedroom Furnished Kitchen shared private Storage spaceTwo bedrooms Unfurnished Bath/Shower shared private

What items would you like to be included in your cost of living expense? Please check all that apply

Utilities Freezer OtherBasic cable LinensInternet ParkingPhone Laundry facilities

What amount are you prepared to budget for each month’s living expenses?Minimum: Maximum: Comments:**You will be required to provide a security deposit equal to one month’s predetermined cost or a

minimum of $200.00 (whichever is more) when starting HomeShare.**

You prefer your Senior to be: Male Female Either Male or Female

Would you be willing to live in a home with pets? YES but not with NO

Do you have any allergies or dietary restrictions? YES, I am NODo you have any other special needs?Do you smoke? YES NO

Do you currently own and operate a vehicle? YES NO

RED DEER HOMESHAREA MUTUALLY BENEFICIAL PROGRAM THAT HELPS TO BRIDGE GENERATIONS

Do you plan to use public transportation? YES NO

Please pick which options best describe you?1. Early riser Night-Hawk2. Sound sleeper Light sleeper3. Often home Often away4. Cook from scratch Pre-packaged meals5. Eat at the table Eat on the run6. Meticulous housekeeper Casual housekeeper

What activities/ social groups are you involved with- eg Church groups, clubs, recreation, sports, etc.

Please briefly describe your typical WEEKDAY routine from waking to bedtime

Please briefly describe your typical WEEKEND routine from waking to bedtime

On what date would you like to begin HomeSharing?

Is that date flexible? YES NO COMMENT

How long would you like your HomeShare agreement to last?Less than 6 mos 6-12 mos more than 12 mos

RED DEER HOMESHAREA MUTUALLY BENEFICIAL PROGRAM THAT HELPS TO BRIDGE GENERATIONS

Anything else you would like to share?

How did you hear about Red Deer HomeShare?

Internet Website Newspaper Radio Friend Word of mouth Poster/Brochure

What sounds appealing about HomeSharing?

Are there any concerns you have aboutHomeSharing?

Please provide us with an emergency contact in case we cannot reach you

NAME RELATIONSHIP DAY TIME PHONE NUMBER

Please provide us with three references who know you well. At least one can be a personal friend or relative. Other suggestions are a past or current employer or teacher/instructor…

NAME RELATIONSHIP DAY TIME PHONE NUMBER

RED DEER HOMESHAREA MUTUALLY BENEFICIAL PROGRAM THAT HELPS TO BRIDGE GENERATIONS

Agreement/ ConsentI hereby consent that the information in this application is true and correct. I understand that misrepresentation may result in the immediate termination from the HomeShare contract and removal from the program.

Signature Date

I consent to the Red Deer HomeShare Program to share any or all information in an attempt to identify suitable HomeShare matches.

SignatureDate

*if done online signature will be completed during a future in-person interview