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Application - Home Provider
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Application - Home Provider
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Application - Home Provider
Information message
This program is
only
for individuals 55 years and older.
This is
not
a rapid housing program, most matches take at least 8 weeks.
This is
not
a caregiving program or a replacement for caregiving.
After submitting the application, you will get to a confirmation page. If this does not happen, please contact us.
Once your application is submitted, please give staff 10 days to reach out to you. We appreciate your patience.
First Name
Last Name
Phone Number
Email
Street Address
Street Address Line 2
City
State/Province
- None -
Postal Code
Birth Date
Your Preferred Language
Afrikaans
Albanian
Arabic
Bulgarian
Catalan; Valencian
Chinese (Mandarin)
Chinese (Cantonese)
Czech
Danish
Dutch (Netherlands)
English (Australia)
English (Canada)
English (United Kingdom)
English (United States)
Estonian
Finnish
French (Canada)
French (France)
German
German (Swiss)
Greek, Modern
Hebrew (modern)
Hindi
Hungarian
Indonesian
Italian
Japanese
Khmer
Lithuanian
Norwegian Bokmål
Persian (Iran)
Polish
Portuguese (Portugal)
Romanian, Moldavian, Moldovan
Russian
Serbian
Slovak
Slovene
Spanish
Swedish
Telugu
Thai
Turkish
Ukrainian
Vietnamese
Dutch (Belgium)
I am age
55-60
61-70
71-80
81-90
91 and older
Annual Gross Income
0 - 14,999
15,000 - 24,999
25,000 - 39,999
40,000 - 59,999
60,000+
I am looking for help with services in exchange for decreased rent
Yes
No
Unsure
I have a cat
No
Yes
I have a dog
No
Yes
I identify as
- Select -
Female
Male
Prefer not to answer
Prefer to self describe
The home is in
Denver County
Arapahoe County
Jefferson County
Adams County
Broomfield County
El Paso County
Aurora
Current Living Situation
Currently Own Home
Renting
Other
How long have you been living at your current living situation?
Less than 1 year
1-5 years
6-10 years
11+ years
How did you hear about Sunshine Home Share?
Word of Mouth
Media (TV, Radio, Flyer)
Resource Fair
Internet Search
Housing Agency
County Human Service Agency (Denver, Jefferson, Arapahoe)
Social Service Agency
Other
If you own your own home, is it in good status and not in foreclosure
No
Yes
Are you current on all your utilities and bills
No
Yes
If renting: Landlords Name
If renting: Landlord's Phone#
Number of people living in the home
1
2
3
4
5+
If other people are living in the home, what is their relation to you
The maximum rent I am asking for
- Select -
$200
$300
$400
$500
$600
$700
$800
$900
More than $900
Not sure
Ethnicity
- Select -
American Indian/Alaskan Native
Asian
Black/African American
Hispanic/Latino
Middle Eastern
Native Hawaiian/Pacific Islander
White
Do you have a disability?
- None -
Yes
No
Are you an immigrant, migrant, or foreign-born?
- Select -
Yes
No
Are you a veteran?
- Select -
Yes
No
Are you a refugee?
- Select -
Yes
No
Do you receive Medicaid?
- None -
Yes
No
Do you receive SNAP (Supplemental Nutrition Assistance Program)
No
Yes
Highest Level of Education?
Not a High School Graduate
High School
College
Advanced Degree
Do you have any motor vehicle violations in the past five years?
No
Yes
Do you have any criminal history in the past 5 years where you were convicted or pled guilty to?
- Select -
No
Yes
At any time, have you been convicted of or pled guilty: (a) offenses against the person such as homicide, assault, battery, kidnapping, unlawful sexual behavior, human trafficking and slavery, stalking; (b) offenses involving the family relations such as bigamy and incest, wrongs to children, harboring a minor, contributing the delinquency of a minor and domestic violence, (c) offenses relating to methamphetamine, and (d) any sex offender offenses?
- Select -
No
Yes
Do you have a good credit history
- Select -
No
Yes
Emergency Contact
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Email
Power of Attorney
I have a power of attorney
No
Yes
Power of atttorney's name
Power of attorney's phone number
Release of Information
I hereby authorize Sunshine Home Share Colorado ("Sunshine") to disclose to potential home share match candidates any information about me that Sunshine possesses or obtains, including but not limited to information about my personality, lifestyle, age range, job status and needs within a home sharing match. While Sunshine will facilitate the process of matching candidates, I remain responsible for all decisions on the selection, acceptance, and/or rejection of a home sharing arrangement, and I will perform any and all due diligence I believe is necessary to make a decision on whether to enter into a home share arrangement.
I also hereby authorize Sunshine to talk with the listed references below about me in connection with a potential home share arrangement. Discussions with these references may include questions about, among other things, my temperament, personality, home sharing ability, substance abuse, mental health history, etc.
I acknowledge and agree that Sunshine and its personnel (including any licensed health care providers) are not my treating health care provider. I further acknowledge and agree that the information I (and my references) provide to them, including information relating to my mental and physical health, is subject only to Sunshine Homes' policies and procedures on the handling of such information, and not to any state or federal laws governing the confidentiality of health information.
By typing my name and the date and clicking the "I Agree" button, I confirm that I understand and agree to the terms of this Release of Information agreement.
I Agree
Today's Date - Release of Information
Signature - Release of Information
References
Please list 3 references
Reference 1: Name
Reference 1: Relation to Home Share Participant
Reference 1: Address
Reference 1: Email
Reference 1: Phone
Reference 1: Preferred Method of Contact
Phone
Email
Reference 2: Name
Reference 2: Relation to Home Share Participant
Reference 2: Address
Reference 2: Email
Reference 2: Phone
Reference 2: Preferred Method of Contact
Phone
Email
Reference 3: Name
Reference 3: Relation to Home Share Participant
Reference 3: Address
Reference 3: Email
Reference 3: Phone
Reference 3: Preferred Method of Contact
Phone
Email
Liability et al - Owner
Liability Waiver and Release
I acknowledge and agree that:
(1) While Sunshine Home Share Colorado ("Sunshine") helps facilitate the process of identifying and matching appropriate home share match candidates, all decisions on the selection, acceptance, and/or rejection of a home sharing arrangement and/or candidate are made solely by me, based on my own preferences and criteria;
(2) I may be introduced to other potential candidates, but neither Sunshine nor any of its officers, directors, agents, or employees make any representations or warranties to me about any home sharing match candidate, or the candidate's ability to perform his/her obligations under a home sharing arrangement; and
(3) Participation in Sunshine's home sharing program is completely voluntary.
To the fullest extent permitted by law, I, for myself, my minor children (if any), and our heirs, executors, and administrators, hereby irrevocably and unconditionally release and forever discharge Sunshine Home Share Colorado, its officers, directors, employees, and agents from any and all claims, liabilities, losses, damages, expenses, or causes of action, whether known or unknown and whether at law or in equity, arising from, out of, or in connection with the any home sharing arrangement and any other services or support provided to me during my participation in the home sharing program ("Claims"). I agree to refrain from directly or indirectly asserting any claim or demand, or commencing, instituting or causing to be commenced, any proceeding of any kind or nature against any person or entity released by this agreement that may arise from or may be based upon any matter purported to be released by this agreement. I further agree that Sunshine is not now and shall not in the future be obligated to supply financial support for the Home Owner or Home Seeker, which financial support is and shall remain the exclusive responsibility of the Home Owner and the Home Seeker, respectively.
By typing my name and the date and clicking the "I Agree" button, I confirm that I understand and agree to the terms of this Liability Waiver and Release agreement.
I Agree
Today's Date - Liability Waiver
Signature - Liability Waiver
Non-Discrimination Agreement
Sunshine Home Share Colorado does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, military status, the presence of minor children, receipt of public assistance or gender identity in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, and clients. Everyone who participates in our program and services must agree to abide by this policy of non-discrimination. For this reason, while it is your decision regarding who you want to live with, we require you to be willing to meet match candidates who are different than you as part of the home share match process.
By typing my name and the date and clicking the "I Agree" button, I confirm that I understand and agree to abide by this Non-Discrimination Policy of Sunshine Home Share Colorado.
I Agree
Today's Date - Non-Discrimination Agreement
Signature - Non-Discrimination
By typing my name and the date, I confirm that I understand and agree to the terms of these agreements.
Type In Today's Date
Electronically Sign Your Name