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Self-Directed Home Support Application


 

CLIENT INFORMATION


 

ELIGIBILE SERVICES:

  • Sweeping
  • Vacuuming
  • Laundry
  • Meal planning and preparation
  • Light cleaning
  • Clean bathrooms
  • Light gardening/plant care
  • Rotation of groceries
  • Cleaning fridge/freezer
  • Dusting
  • Mopping
  • Washing dishes
  • Organization
  • Change bedding and/or linens
  • Light snow shoveling
  • Respite
  • Companionship

 Prior to remitting expenses to the Saddle Hills County Self Directed Home Support Program, I agree to the following:

  1. I, , acknowledge the information collected on these forms will be used to determine my eligibility to this program.
  2. I am a resident of Saddle Hills County.
  3. I understand this program is administered on a first-come, first-serve basis.
  4. I understand that I am solely responsible for hiring someone to perform the eligible services described within this application. I cannot remit for any services that are not eligible under this program.
  5. I am responsible for performing background and reference checks for whomever I hire.
  6. I agree to submit receipts only for completed work that is eligible as described in this application.
  7. I understand that Saddle Hills County will pay a maximum of $300.00 per month (based on 15 hours/month @ $20.00/hour) for completed work.
  8. If my application is approved, I agree to provide Saddle Hills County a direct deposit form.
  9. I agree to notify the Saddle Hills County staff of any changes in my circumstances that would alter my agreement with them.
  10. The subsidy will be terminated if the I am no longer eligible for these services.
  11. This application will expire on December 31 of each calendar year.

Declaration of Understanding

I fully understand all of responsibilities required of me by the Self-Directed Home Support Program.

I certify that the information I provided is true and complete to the best of my knowledge. I am aware that if such information has been falsified, I may be terminated from the Self-Directed Home Support Program.

Clear

Notice of Collection

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of addressing issues and concerns raised by members of the public and in case any follow-up information is required. Direct any questions about this collection to:  FOIP Coordinator, Saddle Hills County, RR 1, Spirit River, Alberta, Canada, T0H 3G0, 1-888-864-3760.