HOMEOWNER REGISTRATION – LIVE-IN LONDON
You do not have to fill in all the sections, only the information that is relevant to our search and to your potential Sharer. If you wish to go ahead with the service, you may like to let a friend or relative have a look at the form, and post back at a later date. You may wish to provide us with additional information on a separate sheet.
Signing and returning this Registration form to Share & Care is deemed as acceptance of Share & Care’s Terms and Conditions [attached], and as confirmation that you would like to proceed.
HOMEOWNER DETAILS & INFORMATION:
Name: ______D.O.B: ______
Address: ______
______Postcode: ______
Tel: ______Fax: ______
Mobile: ______Email: ______
Location/transport [closest BR station, tube and distance from these]: ______
______
Religion:______What name would you like to be addressed by? ______
Emergency contacts:
1. Name and relationship: ______
Tel: ______Mobile: ______
Address: ______
Email: ______
2. Name and relationship: ______
Tel: ______Mobile: ______
Address: ______
Email: ______
Details of any illnesses, disabilities, incontinence, mobility issues, falls / history of falls, memory loss etc: [NB our Sharers are not permitted to give hands-on personal care, such as lifting, bathing, feeding, administering medication] ____________
______
______
Details of any medication: [NB This is for reference only; our Sharers may not administer medication] ______
Summary of requirements:
Why do you want a helper / companion, practical help required? ______
______
______
Key hours of day ______
The Sharer will be entitled to go on holiday. How do you cope at the moment, and how might you cope in their absence? ______
Would you like the Sharer to cook? Yes/ No
Summary of interests [for compatibility, eg walking, animals, music, TV, religion – what sort of person would best suit? Male/Female?]:
Any major dislikes? [eg smoking]:
Current situation and timing: When would you like someone to start?
Do you have any other help in the house/garden? ______
Any pets kept? ______Do you like animals? Yes / No. ______
Would you mind having a Sharer who has their own pet, such as a dog or cat? Yes/No
Do you, or any regular visitors, smoke in the house? ______
How did you hear of Share & Care? ______
Are you registered with any other Homeshare agency? ______
Our Sharers are not permitted to provide personal care [such as lifting, bathing, dressing, administering medication or any such similar personal care services].
I confirm that I understand the above information, and that the information I have given is correct and I have read and accepted your Terms & Conditions.
Signed: ______Date: ______
Name printed: ______
SUPPORTING INFORMATION
DETAILS OF ACCOMMODATION:
Are you the Homeowner? Yes / No [If No, please give details: ______]
Do you have broadband? Yes/No
If you don’t already have broadband, will you be happy to add broadband to your landline? Most Sharers will require broadband. Yes / No
Please give a brief description of the accommodation: Single / double room? Will the Sharer have their own bathroom/shower or is it shared? Is it a house or flat? Is there a garden? Is there a TV in the room?
______
Is there a microwave? ______Does the bath have a shower attachment? ______
Do you have a washing machine? ______Do you have a dryer? ______
Do you get your boiler / gas oven serviced annually by a Corgi-registered engineer? ______
[This is a requirement for having a Sharer. The engineer must provide you with a service report and/or Gas Safety Certificate]
Do you have working smoke alarms on each floor of your home? ______
[Please note that this is a requirement of having a Sharer and you will need to fit them before a Sharer moves in]
Do you have a working carbon monoxide alarm in rooms with a gas boiler or usable fireplace? ______
[Please note that this is a requirement of having a Sharer and you will need to fit them before a Sharer moves in]
Do you have a burglar alarm? ______Does the front door have a 5-lever mortise lock? ______
Do the ground-floor windows have locks? ______
Council Tax: Only full-time students are exempt from Council Tax. If you accept a Sharer who is not a student, you may lose your single person discount on your council tax. You should contact your own council to discuss your situation as there may be variations from council to council. In some cases, we may be able to ask non-exempt Sharers to make a small contribution to your council tax, to assist you with the loss of your single person discount.[Please note that we recommend a Sharer contributes no more than £25 per month if not exempt.] What is the value of the discount you currently receive as we would need to discuss this in advance with you and any potential Sharer how this cost might be covered? £______
Home insurance: Please contact your Household Insurance Company to ensure that your home insurance remains valid if you have a Sharer. Explain that the Sharer is classed as a volunteer who will live in your home on a licence, agreement providing help with household tasks and staying overnight for at least 5 nights each week in exchange for free accommodation.
COOKING / DIETARY REQUIREMENTS
If you would like your Sharer to cook, it would be helpful to know a little more about your likes and dislikes and any specific dietary requirements so we can try to match a Sharer with the right skills and experience:
Any allergies or special dietary requirements: ______
[such as gluten free, nut free, vegetarian, vegan, religious]
Favourite dishes: ______
Eg English meals, spicy food, Italian?
Dislike dishes:______
EMERGENCY CONTACTS AND OTHER KEY NUMBERS:
If you are interested in proceeding with Share & Care, we also offer you the opportunity for us to hold some of your key contact numbers, so if you, a friend/relative, or your Sharer need them in an emergency, we have them to hand.
Do you have any other care support? Full details and contact names/numbers:
Doctor’s name/surgery: ______Tel: ______
Dentist: ______Tel: ______
What contact, if any, would you like us to have with family or a nominated representative? ______
______
______
Are we given permission to give information to a nominated representative? Yes / No
Name of family contact or representative: ______
Tel: ______Email: ______
Address: ______
Level of information we are allowed to divulge: ______
______
Please note that any photographs you provide may be used to support our advertising for a suitable Sharer. Please note that we take every effort not to use photographs that could identify the person or the location. If you do NOT give permission for us to use photographs in this way, please tick this box.
Share and Care Homeshare Ltd, Chestnut Suite, Thornton House, Thornton Road, London SW19 4NG
Tel: 020 3865 3398 / 020 8405 6316, Email: ,
Registered in England & Wales- Company No: 09898282. Registered Office 265-269 Kingston Road, London, SW19 3NW. VAT number 229418496