INFORMATION FOR APPLICANTS
Please complete this Expression of Interest form if you would like to be considered as a Home Share provider.
Name
HOME SHARING EXPRESSION OF INTEREST FORM
Address
Home Phone
Cell Phone
Email
Do you or others smoke in your home?
Yes
No
Describe any pets in your home.
Describe your home including any accessibility features (e.g. wheelchair accessible; one level; grab bars; suite).
Do you have a contractual or service relationship with any of the following: MCFD, CLBC, Home Share Contractor or your School District?
Which support options are you are interested in?
Yes
No
Yes
No
Full Time Home Sharing
Respite (short stay)
When are you ready to start?
Do you work outside of the home?
Enter the letters or numbers exactly as they appear.
Click for new image
Full Time
Home Sharing
Respite
(short stay)
Provide any other details you think we should know about.
Please click the SEND button to submit your information.
Describe the type of person that would be a good fit in your home.
Head Office:
23535 - 44th Avenue
Langley, BC, V2Z 2V2
Office Hours:
8:00 am to 4:00 pm
Monday to Friday
Phone: 604-534-8611
Fax: 604-534-4763

main@langleyacl.com
 
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LANGLEY ASSOCIATION
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