PGS Guardian Application – SUPPORTMATCH HOMESHARE

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PGS GUARDIAN APPLICATION

Please complete all required sections of this form ( *)

IMPORTANT INFORMATION

To avoid delays with the processing of your application we recommend that you have the contact details for two referees to hand in support of your application. *IMPORTANT: Please try to use the following browser when completing your application CHROME, MICROSOFT EDGE, FIREFOX (If you have blocked all cookies you may have issues submitting your form)

YOU MUST COMPLETE ALL REQUIRED FIELDS OTHERWISE YOU WILL NOT BE ABLE TO SUBMIT YOUR APPLICATION FORM

BY COMPLETING AND SUBMITTING THIS APPLICATION FORM YOU ARE AGREEING TO OUR

PROPERTY GUARDIAN TERMS & CONDITIONS

I am at least 18 Years of Age:*

Yes

Please select the relevant Guardianship application option. This is a :*

Single Person Guardian Application

Couples Guardian Application

PREFERRED LIVING LOCATIONS

Please provide the names of at least two Cities/Towns where you would like to live

1st choice (City/Town)*

2nd choice (City/Town)*

3rd choice (City/Town)

I CONFIRM THAT I WILL NOT USE THE PROPERTY FOR BUSINESS OR PUBLIC EVENTS AND ONLY USE THE PROPERTY FOR RESIDENTIAL PURPOSES*

YES

DO YOU HAVE A RELIABLE SOURCE OF FUNDS TO PAY YOUR MONTHLY GUARDIANSHIP FEES*

YES

DO YOU HAVE A CURRENT UP-TO-DATE DBS CERTIFICATE*

YES

IMPORTANT INFORMATION: ENHANCED DBS CHECK FEE
All Homesharers and Guardians are required to have a valid up-to-date ENHANCED DBS CERTIFICATE to be considered for Supportmatch Homeshare or Supportmatch Guardianship, and as such if you do not have an up-to-date Enhanced DBS Certificate then we will send you a link to complete your DBS CHECK.

To cover the costs of your Enhanced DBS Check, Supportmatch will issue you with an invoice for £15 only after your registration interview and if you are successful at the registration stage and accepted on our Homeshare/Guardianship Programme!

The DBS Certificate which is yours to keep will be sent to you only once it has been completed. Furthermore, you will also be granted access to a 12 month free update service with the DBS Issuing Authority.

*Note that an enhanced DBS usually costs significantly more, but as a Community Interest Company we have secured favourable discounted rates for our Homesharers and Guardians.

You are welcome to seek out your own provider for obtaining an Enhanced DBS CHECK and Certificate.

ARE YOU ABLE TO PROVIDE A GUARANTOR IN SUPPORT OF YOUR APPLICATION (IF REQUIRED)*
YES
NO

ARE YOU WILLING TO LIVE WITH ANOTHER INDIVIDUAL AND AGREE TO RESPECT THEIR PROPERTY AND PRIVACY*
YES
NO

ARE YOU A UK RESIDENT*
YES
NO

ABOUT YOU

First Name*

Last Name*

Please upload a recent photo of yourself for identification purposes*
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Please ensure you upload a recent photo of yourself for identification purposes. The file should not be more than 5 MegaBytes!

DOOR BUILDING Number or Name*

STREET/ROAD NAME*

CITY TOWN*

POST CODE*

TELEPHONE*

EMAIL*

DATE OF BIRTH*
DD/MM/YYYY

GENDER*
MALE
FEMALE
OTHER

How did you hear about the Guardianship Programme:*

EMERGENCY CONTACT INFORMATION

Emergency Contact Full Name*

Emergency Contacts Full Address*

Emergency Contacts Email*

Emergency Contacts Telephone*

ABOUT YOUR WORK OR STUDIES

JOB/COURSE TITLE*

WEEKLY HOURS (Work/Study)*
Weekly Work/Study Hours

Describe your Work and/or Studies:*

Company / Instituion Name

Integrated Care System (NHS Staff Only):

Location (City/Town)*

HEALTH & WELLBEING

HEALTH CONDITIONS*
Not Applicable
Not Applicable
Rather Not Say
Alzheimer's Disease
Anxiety
Arthritis
Bi Polar Disorder
Cancer
Cardiovascular Disease
Cognitive Decline
Dementia
Depression
Diabetes
Endocrine Disorders
Food Allergies
Gastrointestinal Issues
Hearing Impairment
High Blood Pressure
Memory Loss
Mobility Issues
Osteoporosis
Parkinson's Disease
Respiratory Disease
Sleep Disorders
Stroke
Uninary/Bowel Issues
Vision Impairment
OTHER NOT LISTED

OTHER HEALTH CONDITIONS NOT LISTED ABOVE

Are you happy to offer at least 3 hours per week of companionship or help to the Householder: Please describe what kind of help you may be able to offer the Householder around the home:*

GUARANTOR DETAILS (If Required)

Guarantors Full Name

Guarantors Email Address

Guarantors Telephone

FURTHER INFORMATION (Referees)

Referee 1: Full Name*

Referee 1: Email Address*

Referee 1: Telephone*

Referee 1: Relationship to you*

Referee 2

Referee 2: Full Name*

Referee 2: Email*

Referee 2: Telephone*

Referee 2: Relationship to you*

IF MY APPLICATION IS SUCCESSFUL I HEREBY AGREE:
APPLICANT ATTESTATION & AGREEMENT*
To respect and abide by the Support&Match CIC Guardianship Licence Agreement
To pay the monthly Guardianship Licence Fee by monthly standing order or Direct Debit
To Support&Match CIC holding records of my personal data and information strictly for office and administration use only
To have an enhanced DBS and Reference checks
And confirm that I have understood the information in my application, and that the information I have provided is to the best of my knowledge accurate and that I have read, understand and accept the Guardianship Terms and Conditions of Services
Registration Date
APPLICATION TYPE (Admin)