Share My Home – Online Application Form

Name*

Householder Name*

Email*

Phone*

Date Of Birth (Must be at least 18)*

Are you male or female?*
MaleFemale

Current address*

Why do you want to share your home?

Have you discussed this with members of your family?*
YesNo

Do you live alone?*
YesNo

Do you have a spare room ready for a homesharer?*

YesNo

Do you have any medical conditions that may be relevant or your homesharer would need to be aware of?*
YesNo

Would you like 10 hours of support each week?*
YesNo

If you answered YES to above, what support would you require?

Have you any pets?*
YesNo

Have you any preference on male or female homesharer?*

Have you a preference for a professional or student?*

Have you any preference on nationality of the homesharer?*

YesNo

Are you willing to provide a medical certificate from your GP and 2 references?*
YesNo