<p>MEDWAY COUNCIL HEALTH AND COMMUNITY SERVICES</p><p>Shared Lives Initial Application Form</p><p>MEDWAY COUNCIL Shared Lives – Initial Enquiry Form</p><p>1. Personal Details</p><p>Applicant 1 Applicant 2</p><p>Name: …………………………… Name: …………………………..</p><p>D.O.B D.O.B</p><p>Address ………………………… Address …………………………….. ………………………………………. ………………………………………. ……………………………………….. ……………………………………….. ………………………………………. ……………………………………….</p><p>Tel No: Tel No: Daytime: ……………………….. Daytime: ………………………….</p><p>Evening: ………………………. Evening: ………………………….</p><p>Mobile No……………………………………………………</p><p>Email Address ……………………………………………..</p><p>1. How long have you lived at your current address? ………………………………….</p><p>2. Are you living together as a couple / married? Yes / No</p><p>3. Are you interested in offering a long-term placement? Yes / No</p><p>4. Are you interested in offering short breaks? i.e. (weekends or weeks only). Yes / No</p><p>5. Are you interested in offering Kinship Support ? Yes / No</p><p>6. Are you interested in offering Day Support? Yes / No</p><p>7. Have you applied to any other schemes in the past? Yes / No 8. Other people in your household:-</p><p>Name: D.O.B Relationship to you:</p><p>1. </p><p>2.</p><p>3.</p><p>4.</p><p>All applicants will be expected to attend a Preparation Course. The times and dates will be forwarded to you shortly.</p><p>Signed ………………………………………….. Date …………………………</p><p>Signed …………………………………………. Date ………………………..</p><p>Please complete and return to :-</p><p>Shared Lives Lordswood Community & Healthy Living Centre Sultan Road Lordswood Chatham, Kent ME5 8TJ </p><p>Telephone: 01634 337100</p><p>Please tell us where you heard about Shared Lives:</p>