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Home Provider Online Application
A
A
A
Thank you for your interest in HomeShare!
Please fill out all required information on this form and thoroughly read the
HomeShare Participation Agreement and Release
document and
Program Exit Guidelines
before electronically signing and submitting this online application. To participate in the HomeShare program, you must:
1)
Submit this online application after reading the Participation Agreement and Release document and the Program Exit Guidelines; and
2)
Email OR mail the signed
Applicant Background Check Form
and a copy of your Driver License or State I.D. to one of the following addresses:
EMAIL:
Home.Share@ventura.org
MAILING ADDRESS: HomeShare, 646 County Square Drive, Suite 100, Ventura, CA 93003
Personal Information
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
SSN:
*
Phone #1
*
Phone #2
Select Phone #1 Designation:
*
Work
Home
Cell
Select Phone #2 Designation:
Work
Home
Cell
What was your sex at birth?
*
Female
Male
Decline to State
What is your Gender?
*
Female
Male
Transgender Female to Male
Transgender Male to Female
Genderqueer/Gender Non-binary
Decline to State
Not Listed
If not listed, please specify:
How do you describe your sexual orientation or sexual identity?
*
Straight/Heterosexual
Bisexual
Transgender Male to Female
Genderqueer/Gender Non-binary
Decline to State
Not Listed
If not listed, please specify:
Please Indicate If You Are a ...
*
Senior
Single Parent
Veteran
Student
Head of Household
Couple
Number in family:
1
2
3
4
5
6
7
8
9
Number of Adults:
*
1
2
3
4
5
6
7
8
9
10
Number of Children:
*
0
1
2
3
4
5
6
7
8
Preferred Language:
*
English
Spanish
Housing
Dwelling Type?
*
Townhouse
Condo
House
Apartment
Mobile Home
Granny Flat
Description
*
1 Bedroom
2 Bedrooms
3+ Bedrooms
Studio
Duplex
Property of Home
*
Own
Rent
Available Space
Available Bedrooms
*
1
2
3
4
5
6
7
8
9
10
Maximum Occupants/Room
*
1
2
3
4
5
6
7
8
9
10
Amount Charging per Month ($)
*
Required Deposit ($)
*
Service Exchange Desired
*
Yes
No
If Yes - Check All Types of Exchange
*
Cooking
Childcare
Handyman/Garden
Light Chores
Heavy Chores
Transportation
In-Home Care
Companionship
Not Applicable
Comments
Private Entrance
*
Yes
No
Private Bath
*
Yes
No
Furnished Room
*
Yes
No
Either
Space for Furniture
*
Yes
No
Utilities Shared
*
Yes
No
Laundry Access
*
Yes
No
Storage Available
*
Yes
No
Public Transit Access
*
Yes
No
Wheelchair Access
*
Yes
No
Parking
*
None
Garage
Street
Off Street
Do You Smoke?
*
Never
Regularly
Inside
Outside
Will You Accept a Smoker?
*
Yes
No
Outside Only
Do You Have Pets?
*
Yes
No
Comments
Will You Accept Pets?
*
Yes
No
Comments
Employment History
Employment Situation
*
Working Full-Time
Working Part-Time
Retired
Receiving SSI
Unemployed
Employer (if working) *
City
Job Title
Years at job
Employer (optional)
City
Job Title
Years at job
Annual Income ($) * (numbers only)
Income Source *
References
HomeShare asks for references in order for us to try to find the right person for you. Please provide 4 references, including 1 employment reference if applicable. Together the references should cover a span of at least 5 years to the present.
ACCEPTABLE
— Past or Present Roommates • Landlords • Employers • Co-workers
NOT ACCEPTABLE
— Family Members • Significant Others (e.g., boy/girl friends, spouses or life-partners)
Personal references known at least 5 years may be substituted for landlord or professional references at the discretion of HomeShare. Please notify your references that HomeShare will be calling them. Please understand that if you have trouble reaching them, we will have the same trouble, and your application may be delayed.
REFERENCE 1
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
REFERENCE 2
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
REFERENCE 3
*
First
Last
Phone
*
How long has this reference known you?
*
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
*
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
REFERENCE 4 (optional)
First
Last
Phone
How long has this reference known you?
Less than 1 year
1-2 years
2-5 years
5+ years
Relationship
Roommate
Employer
Landlord
Colleague
Teacher
Advisor
Supervisor
Emergency Contact
Emergency Contact #1
*
First
Last
Phone
*
Relationship
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact #2
First
Last
Phone
Relationship
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Personal
Please provide the following personal details to help HomeShare find the right person for you.
Hobbies
*
Reason Seeking HomeShare Match
*
Ideal HomeShare
*
Special Qualities (optional)
Preferences
I would consider a housemate that is ...
*
Female
Male
Younger
Older
Different Race or Ethnicity
Different Religion
Identifies as LGBTQ
From Another Country
Non-native English Speaker
Family
Single Parent with Child
All of the Above
Race & Ethnicity
(Voluntary – for statistical purposes only)
Race – Please Choose One
*
American Indian or Alaska Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Multiple Race
Other Asian
Other Pacific Islander
Other Race
Samoan
Vietnamese
White
Decline to State
Ethnicity
*
Not Hispanic/Latino
Hispanic/Latino
Decline to State
How did you hear of us?
Newspaper
HomeShare Client
Friend
Job
Brochure
Senior Center
Government Agency
Non-Profit
Internet
Presentation
Program Exit Guidelines & Participation Agreement
MUST READ before submitting application:
Program Exit Guidelines
HomeShare Participation Agreement and Release
Home Provider Application Signature
I hereby acknowledge that all the information I have given in this application is true and complete to the best of my knowledge. I certify that I have read and agree to the 1) Program Exit Guidelines and 2) Participation Agreement and Release. I consent to having HomeShare check references and conduct a background check. Please fill out the
Applicant Background Check Form
to get started and email it to
Home.Share@ventura.org
or mail it to 646 County Square Drive, Suite 100, Ventura, CA 93003.
I understand that the information my references provide will not be disclosed to me as part of the screening process. I understand that false, misleading or incomplete information may make me ineligible to receive HomeShare services.
Signature
*
By typing your name and clicking the "submit" button below, you've electronically signed this application.
Date
*
Date Format: MM slash DD slash YYYY
Before You Submit!
Before submitting your application, please check below if you would like to have a VCAAA representative contact you with information about other Agency or Community services.
VCAAA services may be available if program eligibility requirements are met, and if funding for the services continues to be available.
VCAAA Services
Chore Services
Homemaker
Home Modifications
Personal Care
Respite
Counseling
Family Caregiver Assistance
Housing
Health Insurance Counseling and Advocacy Program (HICAP)
Information and Assistance
Long Term Care Services
MSSP – Case Management
Senior Support Line
Senior Nutrition
Transportation
Fall Prevention Classes
Matter of Balance
Stepping On Class
Tai Chi: Moving for Better Balance
Other Community Services
Adult Day Health Care
APS
Emergency Housing/Shelter Information
Grey Law
Gold Coast Veterans Foundation
HSA Homeless Services Resource List
Ombudsman
Support Groups
IHSS or other Caregiver
Other, Not Listed Above
© 2021 • Ventura County Area Agency on Aging