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 Hands in Service is a volunteer-based organization - that means they have individuals volunteering (on their own time) to help clients.

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.

First name

Last name

Primary Phone

Secondary Phone

Address (NOTE: Hands In Service is currently operating only in Kelowna)

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

Year

Month

Day

Reason for Assistance: I have been formally diagnosed 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

List all the agencies you receive help or support from:

Medical Background

Vision

Good

Fair

Poor

Other

Hearing

Good

Fair

Poor

Other

Memory

Good

Fair

Poor

Smoker

Yes

No

Alcohol Use

None

Occasional

Regular

Cannabis Use

None

Occasional

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

If referred, Referrer's agency/relationship

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.

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.

Personal Information Release

Applicant Signature and Date

Signature field is empty.

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