Application

Are you applying for yourself or on behalf of somebody else?*

---- I am applying for myself I am applying on behalf of somebody else

What is your full name?*

What is your relation to the applicant?*

What is your phone number?*

What is your email?*

All questions below will be about the applicant, not you. Please select yes to acknowledge this.*

---- Yes

Applicant Information

Legal First Name*

Preferred First Name*

Last Name*

Your last name will not be visible to other users.

Birth Date*

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Your birthdate will not be shared with potential housemates; only your age will be.

I identify as*

---- Female Male Non-binary Prefer to self describe

If you selected "Prefer to self describe" for your gender identity, please specify here*

What county do you live in?*

---- Adams Arapahoe Broomfield Jefferson Denver Other

If you selected "Other" for county, please specify:*

What service exchange would you like? 🫶*

Light housekeeping Gardening Yard Work Pet care Meal Preparation Technology help Transportation Errands Snow shoveling Companionship House Maintenance Presence / overnight security Laundry Other (please specify) No Service Exchange

Are you LGBTQ+ Friendly?

---- 🏳️‍🌈 LGBTQ+ Friendly —

If you prefer not to disclose, skip this question.

All information below is for internal use only. Please select yes to acknowledge this.*

---- Yes

The following information will remain confidential and is for internal use and grant purposes only.

Which of the following best describes your race?*

American Indian or Alaska Native Asian Black Native Hawaiian or Other Pacific Islander White Multiracial Hispanic / Latinx Other / Prefer to self-describe

If you selected "Other / Prefer to self-describe" for your race, please specify here*

Email*

Phone*

Address*

Annual Gross Income*

---- $0-$14,999 $15,000-$24,999 $25,000-$39,999 $40,000-$59,999 $60,000-$79,999 $80,000+

Source of income*

Do you live with a disability that limits some of your daily activities*

---- Yes No

If you selected "Yes" for disabilities, please specify here*

Mobility: uses assistive device Vision: blindness or impairment (even with glasses) Hearing: loss & communication struggles (even with aids) Memory Issues Intellectual or Developmental Disability Physical/emotional issues Personal care: difficulty bathing or dressing Other

If you selected "Other" for disability, please specify here:*

Current living situation*

---- Currently own home Renting Other

If you selected "Other" for current living situation, please specify here*

Are you currently or in the future planning on renting to multiple people*

---- Yes No

Do you have children that will be homesharing with you 🧒*

---- Yes No

If you will have a child / children home sharing with you, describe more here.*

Are you home sharing as a couple?*

---- Yes No

I feel comfortable using technology*

---- Very Somewhat Not at all

How did you hear about Sunshine Home Share?*

Word of Mouth Facebook Instagram Nextdoor Internet Search Resource Fair Social Service Agency Medical Provider Media (TV, Radio, Flyer) Newspaper Other

Please share the name of the organization / person / source of your referral if you know it.

If you selected "Other" for how you heard about Sunshine, please share here*

Are you an immigrant, migrant, or foreign-born?*

---- Yes No

Are you a veteran?*

---- Yes No

Are you a refugee?*

---- Yes No

Do you have any motor vehicle violations in the past five years*

---- Yes No

Please tell us more about these violations

Do you have a criminal history in the past 5 years where you were convicted or is pending*

---- Yes No

Please tell us more about this history

At any time, have you been convicted of or pled guilty to a crime?*

---- Yes No

(a) offenses against the person, such as homicide, assault, battery, kidnapping, unlawful sexual behavior, human trafficking and slavery, stalking; (b) offenses involving the family relations, such as bigamy and incest, wrongs to children, harboring a minor, contributing to the delinquency of a minor, and domestic violence, (c) offenses relating to methamphetamine, and(d) any sex offender offenses?

Please tell us more about these charges.

If you answered "Yes" to any of the above criminal history charges, please tell us a bit more about your situation here.

How often do you feel that you lack companionship?*

---- Hardly ever Some of the time Often

How often do you feel left out?*

---- Hardly ever Some of the time Often

How often do you feel isolated from others?*

---- Hardly ever Some of the time Often

Emergency Contact Name*

Emergency Contact Phone Number*

Emergency Contact Email