Client Application - Hands in Service

Please complete this form to apply for Basic Housekeeping Services only if these pertain to you:*

I am between the ages of 19 and 64 and understand I won't be eligible on and after my 65th birthday.
I have a diagnosed physical impairment that prevents me from completing household cleaning for myself.
I understand that Basic Household Cleaning includes tasks such as: vacuuming, washing dishes, laundry, dusting, cleaning bathrooms, taking out garbage and recycling.
I understand that Hands in Service is a volunteer-based organization - that means they have individuals volunteering (on their own time) to help clients. This service is limited to a maximum of 4 hours per month.
I do not have any financial means to pay for my own basic household cleaning.
I do not have any family or friends who can help pay for my basic household cleaning.
I do not have anyone living in the Okanagan who can help with my basic household cleaning.

Name*

First Last

Primary Phone*

Secondary Phone

Address (Hands in Service is currently operating in the Central Okanagan)*

Street Address Address Line 2 City Province Postal Code

Residence Information:*

I rent my home
I pay a mortgage on my own home
I own my own home

Please include any information required in finding your home (ie Buzz Code, “Go through carport”, “Call ahead and I’ll meet you at the door”, etc.)

Email

Birthday*

Reason for Assistance: I have been formally diagnosed (or are in the process of formal diagnosis) by a medical professional with the following condition(s):*

FAMILY ASSISTANCE:

Are there any other adults living in your home? Name and relationship to you:*

Are there children in the home? Name and birthdate:*

Are any of the above able to assist in household cleaning? Why or why not.*

Do you have any pets : number and type*

INCOME / FINANCIAL STATUS:

Sources of Income*

PWD
Child Tax
Child Support
Social Assistance
CPP
Employment
Other (income from rental rooms/suites, etc.)

List all the agencies you receive help or support from:*

NA if not applicable

MEDICAL BACKGROUND:

Mobility Requirments:*

Wheelchair
Walker
Cane
Crutches
Oxygen
Other
Not Applicable

Vision:*

Good
Fair
Poor

Hearing:*

Good
Fair
Poor

Memory:*

Good
Fair
Poor

Smoker:*

Yes
No

Alcohol Use:*

None
Occassional
Regular

Cannabis Use:*

None
Occassional
Regular

Communicable diseases - identify, if applicable:*

I understand that if I drink, smoke, use cannabis or use recreational drugs, that I will refrain from using these before and during any visits from Hands in Service staff/volunteers.*

I understand

If referred, Referrer's name

First Last

If referred, Referrer's phone number

Additional comments you would like us to know:

I confirm that:*

I can be home for an initial Home Visit that will be scheduled for approximately one hour during the times of Monday to Thursday, 9:00-4:00.
I have my own cleaning supplies for the volunteer to use.
My eligibility will be reviewed in 6 months.

Personal Information Release*

I, (applicant print name below) approve the release of my personal information as shown above with the understanding that this information is required to participate in the Hands in Service program or receive Hands in Service assistance and will only be provided to Hands in Service staff, volunteers or relevant health care providers as part of the Hands in Service program to ensure appropriate service delivery.

First Last

Applicant Signature

Please type your first & last name with today's date as an electronic signature.

Application for Basic Housekeeping Services

FAMILY ASSISTANCE:

INCOME / FINANCIAL STATUS:

MEDICAL BACKGROUND: