Stollery Suites on Spirit Square Housing Application

Housing Type (You may select more than one)

Studio

Adaptable

Accessible

1 Bedroom

Any Unit

Residency in Kamloops

5+ Years

1+ Years

Less than 1 Year

Not a Kamloops Resident

Any household Pets?

Yes

If Yes, what type of Pets?

If Yes, how many Pets?

Household Information

Skip if not applicable

Last Name of Family Member 1

Last Name of Family Member 2

Last Name of Family Member 3

Last Name of Family Member 4

If you have more family members, please input here using the same format as previously outlined

Do You or Your Partner use any of the following?

Cane

Walker

Wheelchair

Scooter

I/We don't use any of these

Do You or Your Partner require physical assistance?

Yes

Are You or Your Partner currently receiving home supports?

Yes

Are You or Your Partner currently enrolled in a meal program?

Yes

Are You or Your Partner currently enrolled in SAFER?

Yes

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Number

Please include Your and Your Partner history

Acute/Chronic Health Issues

Is Assistance Required in the following areas? Please check all that apply.

Not Applicable

Personal Care

Basic Housework

Medication Management

Shopping/Foodbank

Mobility Inside Unit

Mobility Outside Unit

Transportation

Finances

Is assistance required in the following areas?

Parole

Required

Not Required

Is assistance required in the following areas?

Probation

Required

Not Required

Is assistance required in the following areas?

Home Health

Required

Not Required

Is assistance required in the following areas?

Other

Required

Not Required

Is assistance required in the following areas?

Other

Required

Not Required

Financial Information

Please complete the following related to your Financial Situation.

SELF

Other Pension Income

Total Monthly Income

Financial Information

Please complete the following related to your Financial Situation.

CO-APPLICANT

Other Pension Income

Total Monthly Income

1. Pursuant to the Freedom of Information and Protection of Privacy Act (the FOI Act). I hereby authorize the ASK Wellness Society, or its agent, to verify or confirm the above information with any source (whether its named or not in this application) 2. I declare that all the statements in this application form are true to the best of my knowledge, and that no information has been concealed or omitted 3. I agree to notify the Society or its agent immediately if there are any significant changes in my income or any changes to my contact information 4. I agree to forward “proof of annual income: on an ongoing basis when required

Applicant First Name

Co-Applicant First Name

Co-Applicant Last Name

Statement of Confidentiality

ASK Wellness Society (ASK) provides a wide range of services in both individual and group settings. The most important way we ca keep our ASK community safe is to maintain trust. This is done by keeping all ASK matter in the strictest confidence. Therefore, no participant of ASK shall disclose any information; spoken or written; which refers to any members of our ASK Community (clients or staff) Information regarding your involvement with ASK is confidential and protected; however, there are exceptions to our confidentiality where it would be necessary to report specific information. This could include the following situations. • If we become aware that children are being neglected or abused; • If we become aware that a client may do serious harm to themselves or others; • If we have information that would facilitate treatment of a medical emergency; and/or • If an ASK staff member is subpoenaed to court.

Applicant First Name

Please type your name again. This is your signature!

ASK Employee Name Again (this is your signature)

What is your message?

Stollery Suites on Spirit Square Housing Application

Household Information

Medical Information

Daily Living

Is assistance required in the following areas?

Is assistance required in the following areas?

Is assistance required in the following areas?

Is assistance required in the following areas?

Is assistance required in the following areas?

Financial Information

Financial Information

Statement of Confidentiality