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Aspire Richmond
Aspire Richmond
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Home Share Online Application - New Item
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There are items in this form that require your attention
Thank you for applying to be a Home Share Contracted Caregiver. Once you submit your application below, an Aspire Home Share Manager will be in touch with you.
Application Date
Applicant Information
First Name
*
Last Name
*
Email
*
Phone
*
Address
*
City
*
Postal Code
Are you 19 years of age or older?
Yes
No
Level of Support You Can Provide
Teaching Life Skills
Basic
Medium
High
Behavioural Support
Basic
Medium
High
Physical Lifting
Basic
Medium
High
Comments regarding the level of care you can provide
Transportation
Do you have a valid BC Driver's License?
Yes - Class 4
Yes - Class 5
Yes - Other Class
No
Do you own a vehicle?
Yes
No
No - but I have one regularly available to me
Education, Employment and Experience
Are you currently employed?
Yes - Full Time
Yes - Part Time
No
Job Title
What languages do you speak?
Do you have a current first aid certificate?
Yes
No
Education you have completed
Experience with Personal Care - Bathing
Low
Average
High
Experience with Personal Care - Toiletting
Low
Average
High
Experience with Personal Care - Feeding
Low
Average
High
Experience with Administering Medication
Low
Average
High
List any experience, training, knowledge you have that might assist you in supporting adults with developmental disabilities
Have you ever provided residential care in your home?
Yes
No
If yes, please provide details
Information About Your Home
Can the Home Share Manager conduct a Safety Visit at your home?
Yes
No
List all the people who live in your home (spouse, children, others) and include their relationship to you
Are all household members in good health?
Yes
No
Does anyone living in the home smoke?
Yes
No
Are there pets in the home?
Yes
No
Is your home wheelchair accessible?
Yes
No
Do you have a fenced back yard?
Yes
No
Is your home equipped with smoke detectors?
Yes
No
Any additional information about your home you would like to provide
Terms and Conditions
Terms and Conditions of being an Aspire Home Share Caregiver:
As part of our screening process prior to providing support, the following is mandatory and must be completed before starting the matching process with an individual who requires care:
Must be 19 years or older
Physician’s Reference Form
Criminal Record Check – Vulnerable Sector, renewed every 5 years
Valid First Aid & CPR, renewed every 3 years
Work/Character References
Driver’s Licence, Car Insurance (minimum $2 million in 3rd party liability), Driver’s Abstract (car is preferred, not required)
Home Safety Visit and/or Home Study
CLBC Privacy Training (online course)
CLBC Home Share Standards Course (online course)
Home Share Caregiver Orientation
Home Share Services Contract
Do any of the above Terms and Conditions pose a problem for you?
Yes
No
If yes, please explain
By signing your name below, you acknowledge that all information provided on this application form is accurate and true.
Applicant Signature
Please attach your resume by clicking Add Attachment
Home Share Manager Section
Home Share Manager Review Date
Home Share Manager Signature
Application Notes
Application Status
Unreviewed
Not Suitable
Contacted for Interview
Interview Completed - Not Suitable
Interview Completed - Added to Screening List
Interview Waived - Added to Screening List
Attachments:
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