HomeAid Foundation 

SECTION A: Who is completing this form?

I am applying for myself (the person in need of services)

I am applying on behalf of someone else

If you are applying on behalf of someone else, please complete the following:

First Name

Last Name

Phone

(###)

###

####

Mailing Address (if different):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent: “I confirm that I have permission from the applicant (or their legal guardian/power of attorney) to submit this application on their behalf. I understand that HomeAid Foundation may contact both the applicant and myself to verify information or coordinate services.”

I agree

Date

MM

DD

YYYY

SECTION B: Applicant Information *

First Name

Last Name

Birthday (optional)

MM

DD

YYYY

Home Address where cleaning is required: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Preferred Method of Contact: *

Phone

Email

Through Representative

Emergency Contact (optional):

First Name

Last Name

Phone

(###)

###

####

SECTION C *

Eligibility Details (please check any that apply to your situation):

I am living with a disability that limits my ability to clean

I am critically ill or in medical treatment that prevents me from cleaning

I am senior (65+) living independently

I am temporarily unable to maintain my home due to illness, recovery, or other hardship

Are you currently receiving any government support or benefits? (Check all that apply)

Ontario Disability Support Program (ODSP)

Ontario Works

CPP Disability (CPP-D)

Old Age Security (OAS)

Guaranteed Income Supplement (GIS)

Other

None

Approximate Household Income:

Under 30,000

$30,001-$50,000

Over $50,000

Housing Status:

Own

Rent

Other

Are you currently able to clean your home on your own?

Yes

Somewhat

No

Do you live alone?

Yes

No

SECTION D:

Type of Cleaning Assistance Requested: What type of cleaning do you need most urgently?

Deep Cleaning (thorough one-time cleaning)

Regular maintenance cleaning

Organization/decluttering assistance

Other:

How often would this assistance help you most?

One-time visit

Monthly

Bi-weekly

As Needed

Have you received assistance from HomeAid Foundation or Cleaning for a Cause before?

Yes

No

SECTION E: Consent and Privacy *

Confidentiality & Consent By signing below, I confirm that the information provided is accurate and truthful to the best of my knowledge. I understand that: • This information will be used only to determine eligibility for HomeAid Foundation’s Cleaning for a Cause program. • My information will be stored securely and only authorized staff or volunteers will have access. • I may be contacted for verification or to arrange cleaning services. • Providing false or misleading information may result in ineligibility.

First Name

Last Name

If applicable, signature of the legal guardian or authorized representative

First Name

Last Name

Date

MM

DD

YYYY

I agree to the above terms *

Yes, I agree.