LEEDS HOMESHARE - Homeowner Application form
Your details / Date of birthName / Male/Female
Address
Preferred
Language
Telephone number
Email Address
Have you applied to Leeds Homeshare before? / YES/NO
If yes, please give dates
Is there anyone else you would like to be kept up to date on your application, such a family member/friend/professional?
Name: / Telephone (home):
Telephone (work):
Mobile No:
Email:
Address:
Relationship to you:
Please let us know if you would like us to get in touch with this person to arrange appointments?
YES ☐ NO ☐
Do you currently receive any other services? Eg. Social Worker/Support Worker/Volunteers/Homecare.
Please tell us about the type of support you have and how often you receive it:
Your Homesharer will offer 10 hours of support please let us know what is important to you?
What help/support are you looking for?
/ Please tick below your preferenceShopping / YES ☐ NO ☐
Light housework / YES ☐ NO ☐
Laundry / YES ☐ NO ☐
Gardening/care of plants / YES ☐ NO ☐
Light cooking / YES ☐ NO ☐
Keeping Appointments / YES ☐ NO ☐
Companionship / YES ☐ NO ☐
Outings / YES ☐ NO ☐
Care of pets / YES ☐ NO ☐
Overnight presence in the house / YES ☐ NO ☐
Is there anything else you would like help with?Please tell us:
When do you need a Homesharer from?
How long would you like a Homesharer for?
Tell us about the accommodation on offer to the sharer
I own my home ☐ / I rent my home ☐ / Other, please detail
Please confirm that you have a spare room available
Double room, shared bathroom ☐ Single room, shared bathroom ☐
Double room, en-suite ☐ Single room, en- suite ☐
Is the room furnished?
Furnished, including bed and mattress ☐Unfurnished ☐
Other members of your household, if any:
We need to know this information as who (if anybody) lives with you may effect whether your tenancy and/or benefits are affected and in what way- we will be able to help you with any benefits or tenancy matters that result from the Homeshare.
Name / Date of Birth / RelationshipHow Leeds City Council will use the information collected on this form
I understand and agree that;
The information collected about me on this form is needed to assess my suitability for the Homeshare scheme, and I agree to my information being collected and used for this purpose.
I can withdraw my agreement to my information being collected and used for this purpose at any time by contacting the Homeshare team. However, this may mean that my application to the Homeshare scheme is withdrawn.
To support me in making sure that my home is ready for Homeshare it may be useful for my information to be shared with the following organisations. Leeds City Council will ask me for my permission before it shares any of my information with these organisations;
- Warmth for Wellbeing
- Care and Repair
- Charities for the purpose of obtaining grants
- Leeds Housing/Registered Social Landlords
- West Yorkshire Fire and Rescue Service
- Myinformation must be sharedby law.
- There is a serious risk to me or to somebody else if my information is not shared.
- There is a good reason to share my information, for example if a serious crime has been committed.
- To ask for a copy of myrecords;
- To request that myrecords be corrected if they are wrong; and
- To ask Leeds City Council to change or remove my information if this is causing me harm or serious distress.
Signature……………………………… Date……………………………………..
Name……………………………………….
Advocate/Representative Signature (if appropriate)
…………………………………………………..
Advocate/Representative Name (if appropriate)
……………………………………………………..
for office use only
If application form completed by telephone;
Section ‘HowLeeds City Council will use the information collected on this form’ has been read in full to the applicant and/or their advocate/representative, and the applicant/advocate/representative has confirmed that they understand and agree to the contents of the section☐Yes
Name of officer completing form:
Date:
Thank you for completing a form for Homesharing. Please return the form to:
Homeshare, Leeds Shared Lives
Adult Social Care
Leeds City Council
Central Mail Room
Westland Road
LEEDS
LS11 5SB
Please let us know if you would like us to send you prepaid envelope
We are happy to take your application by telephone, please call and ask for the Homeshare team
TEL: 0113 37 85410
To avoid the risk of identity theft, we would advise you not to return your application by email as you are sending sensitive information over an unsecured network. Please let us know if you would like to send your form by email and we will send you a link to use secure email.
G/Shared Lives/Homeshare/Documents/Enquiry and Referral/Homeowner Application