Kardel Application for Home Sharing

Kardel Application for Home Sharing - New Item

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**IMPORTANT NOTICE:**

Please note that this form cannot be saved for later completion. Once you begin filling it out, you must complete and submit it in one session. You will not be able to return to your work on this form after leaving the page or submitting it.

Ensure all information is accurate before proceeding.

Thank you for your understanding.

Kardel only approves those with the skills, disposition, and physical accommodation to provide high quality home sharing support to adults with a developmental disability.

Home Share Coordinators complete a rigorous and comprehensive assessment prior to approving any home sharing provider. Approval does not necessarily guarantee that a contract will be established with the potential provider.

Contracts will be established when the individual, his / her family, or support network members decides whether or not a potential candidate meets the individual’s needs and preferences for support.

Kardel-contracted home sharing providers support only one individual at any given time. Exceptions can be considered if beneficial to the first individual in the home.

Date of Submission *

Primary Applicant

Last Name

First Name

Date of Birth

Address

Phone

Languages Spoken

Current Employer

Position

Length of Employment

Please provide the following information if you have a direct relative or share the same household with an individual employed by Kardel, i.e.: parent, spouse, common law partner, brother, sister, grandparent, son, daughter, or roommate.

Note: This will not impact your eligibility.

Name/Relationship

Worksite/Home/Program

Please list the names of all the people living in the home where the support services will take place:

Name 1:

Name 1: Relationship to the primary candidate

Name 1: Birthdate

Name 2:

Name 2: Relationship to the primary candidate

Name 2: Birthdate

Name 3:

Name 3: Relationship to the primary candidate

Name 3: Birthdate

Name 4:

Name 4: Relationship to the primary candidate

Name 4: Birthdate

Name 5:

Name 5: Relationship to the primary candidate

Name 5: Birthdate

Name 6:

Name 6: Relationship to the primary candidate

Name 6: Birthdate

Name 7:

Name 7: Relationship to the primary candidate

Name 7: Birthdate

Tell us about your decision to provide home sharing:

1. Have you taken the time to discuss this decision with everyone in your household, and do they fully support it?

Yes

2. What do you know about providing home sharing for adults with a developmental disability?

3. Why are you considering home sharing at this time?

4. How will others be impacted by this decision (children, partner, others living in the home, etc.?)

5. Do you have friends or family outside of the home who support you? How will your decision to provide home sharing affect them?

6. How would your decision to provide home sharing support impact your overall lifestyle, regular schedule, commitments, and priorities?

7. How long are you able to commit to providing this kind of support?

Tell us about your work history:

1. Briefly outline your work history. Highlight any work experiences that are relevant to supporting individuals with a developmental disability.

2. List the members of you and your household who are currently employed. Provide details about their employer, position, length of employment, and work schedule.

Household Member 1: Name

Household Member 1: Position

Household Member 1: Length of Employment

Household Member 1: Work Schedule

Household Member 2: Name

Household Member 2: Position

Household Member 2: Length of Employment

Household Member 2: Work Schedule

Household Member 3: Name

Household Member 3: Position

Household Member 3: Length of Employment

Household Member 3: Work Schedule

Household Member 4: Name

Household Member 4: Position

Household Member 4: Length of Employment

Household Member 4: Work Schedule

Household Member 5: Name

Household Member 5: Position

Household Member 5: Length of Employment

Household Member 5: Work Schedule

Household Member 6: Name

Household Member 6: Position

Household Member 6: Length of Employment

Household Member 6: Work Schedule

Household Member 7: Name

Household Member 7: Position

Household Member 7: Length of Employment

Household Member 7: Work Schedule

3. Have you ever provided home sharing, foster care, or respite support? If so, please provide details (agency name, dates, etc.).

4. Are you currently supporting an individual with a developmental disability in your home? If so, please provide details.

5.What other agencies, if any, are you approaching about home sharing?

6. Have you been screened (partially or completely) by another agency who provides home sharing? If so, please provide details about which agency you were screened by, when this occurred and the outcome of the process.

Tell us about your home:

1. Do you own or rent your home? If you're renting, have you discussed the concept of Home Sharing with your landlord and assessed their support for your involvement in such arrangements? If you reside in a Strata, have you engaged with the Strata Board?

2. What kind of home do you have (condo, apartment, townhouse, detached home, etc.)? Briefly describe the home (square footage, one-story / two-story, number of bedrooms / bathrooms, layout / design features etc.) and the exterior space.

3. Please describe the space which will be available for the supported individual, (bedroom/ suite, sitting areas, shared or private, size, furnishings, etc.)

4. Does the home have any features that limit or improve accessibility for individuals with a physical disability or mobility challenges? Please describe.

5. Are there pets in the home? If so, please provide details (type, breed, age, disposition). Are you open to supporting an individual who owns a pet? If so, what kinds of pets would be acceptable?

6. Describe your neighbourhood and provide details about proximity to services (schools, parks, community centres, shopping facilities, public transportation, etc.)

Tell us about the Type of Support you are willing and able to provide:

1. Will you be entirely responsible for providing home sharing support or will others in the home be sharing responsibility?

I will be entirely responsible

Others in the home will share responsibility with me

If home sharing support is a shared responsibility, what role/responsibilities will be provided by another member of the household?

2. What are some of the qualities/characteristics/skills/abilities of a supported person you feel would be the best match to your family/home/lifestyle/experience?

I.e., age range, their level of independence; in meal preparation, home alone skills, community access, public transportation skills etc.

Check the appropriate box that best describes your experience and level of ability with the following skills, tasks, and knowledge.

3. Are there any other specific challenges (not noted above) with which you are not comfortable supporting?

4. Do you or any members of the household smoke? How do you feel about supporting someone who smokes, consumes alcohol, uses marijuana, or uses other drugs?

Further Thoughts/Comments

Anything further you would like to let us know?

References:

Please provide a minimum of two professional/employer references and one personal reference. All three will be contacted.

Reference 1: Name

Reference 1: Home Address

Reference 1: Phone Number

Reference 1: Email Address

Reference 1: Place of Employment

Reference 1: Relationship to Candidate(s)

Reference 2: Name

Reference 2: Home Address

Reference 2: Phone Number

Reference 2: Email Address

Reference 2: Place of Employment

Reference 2: Relationship to Candidate(s)

Reference 3: Name

Reference 3: Home Address

Reference 3: Phone Number

Reference 3: Email Address

Reference 3: Place of Employment

Reference 3: Relationship to Candidate(s)

At times other agencies may be looking for Home Share Providers with certain skill sets, and spaces available.

Kardel works to support the larger community and at times may wish to share applications with others to support finding matches for individuals supported and Home Share Providers.

Do you consent to having this application shared with other agencies?

Yes

Do you consent to having your name added to a list for respite providers?

Yes

Declaration:

I / we declare that the information contained in this candidate submission is true to the best of my / our knowledge and believe that I / we have not omitted any requested information.

I / we give permission for Kardel to obtain a reference from any agency that I have named as a previous / current employer or contractor within community living.

This may include CLBC, MCFD (or its predecessors), or community living agencies and may be in addition to the references named above.

I / we understand that the information provided to the questions above is required to ensure that I / we are qualified to be considered as a home sharing provider.

Any false statement will invalidate the submission or my / our status as a home sharing provider.

Primary Candidate: Name

Primary Candidate: Signature

Primary Candidate: Date

Secondary Candidate: Name

Secondary Candidate: Signature

Secondary Candidate: Date

Attachments:

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