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Area Agency on Aging Area Agency on Aging
Dementia Friendly Aging and Disability Resource Center Safe Zone LIVEWell Guide
  • Home
  • Advisory Council
    • Member Biographies
    • Agendas
    • Subcommittees
    • Become a Member
  • Our Services
    • Aging & Disability Resource Center
      • Information & Assistance
    • Benefit Enrollment Center
    • Care Management & Social Services
      • In-Home Support
      • Caregiver Services
    • Emergency Services
    • Fall Prevention
    • Health Insurance Counseling (HICAP)
    • Housing
    • Legal Services
    • Nursing Facility Services
    • Senior Employment Training
    • Senior Nutrition Program
      • Meal Service Locations
      • Health Promotion Programs
      • Senior Nutrition Garden
    • Transportation
  • For Providers
    • Public Notice & Request for Proposal
    • Vendor Service Tools
    • Grantee Service Tools
  • News & Events
    • Calendar
    • Video Shorts
    • Press Releases
    • Publications
  • About Us
    • Contact Us
      • Subscribe to E-Notify
      • Nondiscrimination
    • Mission
    • Employment
    • Volunteers
    • Planning & Strategy
    • Advocacy
      • Dementia Friendly Ventura County
      • Legislative Issues
      • Ombudsman
      • Employ Older Workers
      • LGBT Elders
    • Resources

Home Provider Online Application

  • 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









  • Housing


  • Available Space





  • Employment History




  • 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 • Friends • Neighbors
    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.



  • Emergency Contact




  • Personal

  • Please provide the following personal details to help HomeShare find the right person for you.


  • Preferences



  • Race & Ethnicity

    (Voluntary – for statistical purposes only)



  • 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.
  • By typing your name and clicking the "submit" button below, you've electronically signed this application.

  • 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.
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Location Information

  • Ventura County Area Agency on Aging
  • 646 County Square Drive, Suite 100, Ventura, CA 93003
  • 805-477-7300
  • LOIS.VCAAA@ventura.org
  • www.referweb.net/vcaaa

Quick Links

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Resources

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