LEEDS HOMESHARE - Homesharer Application form

Your Details / Date of birth
Name
(for couples please provide both applicant details) / Male/Female
Address
Preferred
Language
Telephone number
Email Address
Have you applied to Leeds Homeshare before? / YES/NO
If yes, please give dates
Section 1 - Your Accommodation Needs
How soon do you need accommodation?
Do you need to give notice where you are currently living, if so how much?
Which areas are you willing to live?
(Please note the wider range of areas you give the easier it is to find a placement) / 1.
2.
3.
4.
Do you have an UK or EU passport
We ask this question as for non EU Nationals a Homeshare may have some implications we need to check out with you. / YES ☐ NO ☐
How long can you commit to Homesharing?
( We need at least a six month commitment)
Do you have any health needs which you think we/ and the Householder should be aware of?
(please include any allergies)
Section 2 - Your experience and interests
What attracted you to the idea of Homeshare?
Do you have any qualifications or experience with older/vulnerable people?
As a Homesharer you will need to offer 10 hours of support, please let us know what kind of support you can offer to the Householder?
Type of support / Please tick below if you are able to offer
Shopping / YES ☐ NO ☐
Light housework and 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 to offer help with? Please tell us:
Section 3 - Your commitments
Please complete both sections if working and studying
If working
What is your occupation? / How many hours do you work a week?
If studying
What if your course? / Which year are you in?
How many years do you have left on your course? / How many hours a week are you in college/university?
Are you able to provide 10 hours support per week
YES ☐ NO ☐
Do you have any upcoming commitments, including holiday plans and plans to travel
YES ☐ NO ☐
If yes please detail
Section 4 – References
Please provide details of two references – one professional (your current or most recent employer or learning establishment) and one character reference.
If references are required you will be asked at assessment stage whether you consent to us contacting your referees to obtain references. If references are obtained they will only be used for the purpose of assessing your suitability for the Homeshare scheme and will not be used or shared for any other purpose.
Work Reference
Name
Address
Telephone Number
Email Address
Capacity in which known
Length of time known
Personal Reference
Name
Address
Telephone Number
Email Address
Capacity in which known
Length of time known
Section 5 – Next of kin
Please provide details of you next of kin. This should be a parent, relative or guardian
This information will be used as an emergency contact if needed during Homeshare.
Name / Relationship
Address
Telephone Number
Email Address
How 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.
If my information needs to be shared for any other reason Leeds City Council will ask me for my permission to share my information first, unless;
  • My information must be shared by 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.
Under Data Protection law I have the following rights;
  • 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.
Leeds City Council will make sure that my information is kept safe and secure.
If my application is successful;
I will pay the monthly contribution of £150.00 to Leeds Homeshare from the date of my first placement / Yes / ☐
Leeds Homeshare may conduct an enhanced DBS check / Yes / ☐
I will provide proof of income to Leeds Homeshare as part of a credit check / Yes / ☐
I will provide 10 hours of support to the householder per week / Yes / ☐
Signature______Date______
Name______
for office use only
If application form completed by telephone;
Section ‘How Leeds City Council will use the information collected on this form’ has been read in full to the applicant, and the applicant 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 a 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/Homesharer Application