Respite Supportive roommate Form – Dynamite Respite And Community Services

Applicant's Name *

First

Last

Email *

Address *

Phone number: *

Marital status: *

Any children?

Number of children (If Applicable)

Ages of children? (If Application)

Type of home?

Detached

Does the client have their own bedroom/bathroom? (We will request for pictures and pay a visit to confirm accommodation)

As a Respite Supportive Roommate, you are required to provide care and support to clients and be able to take them into the community on every visit for recreation, sports, games and parks as the case may be. Do you consent to this?

WE WILL ONLY PROCESS APPLICATIONS FROM APPLICANTS WHO CONSENT.

Will you consent to a visit by our intake representatives?

WE WILL ONLY PROCESS APPLICATIONS FROM APPLICANTS WHO CONSENT.

Anything else we should know?