To apply for an Oxford House home, simplyFill out the below application form.You will be called in for an interview with an Oxford House Support Worker.Depending on vacancy and fit, you will be scheduled for a second interview with the residents of the home you have been recommended for.To follow up on the status of your application, send an email to support@oxfordhouse.ca and indicate which city you’ve applied for housing. Oxford House Application I am applying for a home in * Calgary Edmonton Drumheller Pre-Treatment (Calgary) Name * First Name Last Name Email * Phone * (###) ### #### Birthdate * MM DD YYYY Alberta Healthcare # * Gender * Male Female Other Are you First Nations? Are you Metis? Please circle the one that applies or use the drop down field * First Nations Metis Other Are you homeless? * Yes No What is your main addiction and have you ever utilized the services of a safe consumption (injection) site? * What else are you addicted to? Please indicate N/A if this does not apply to you. * What drugs have you used in the past year? Please indicate N/A if this does not apply to you. * Do you have a gambling addiction? * Yes No Last Date Gambled. Please indicate N/A if this does not apply to you: List any treatment you have had in the past or are taking now for your addiction. * Pease include name, date of treatment and reason for leaving. What is the longest time you have been clean and sober? * Date of last drink? MM DD YYYY Date of last drug? MM DD YYYY What recovery meetings will you attend each week? * AA NA CA GA SMART AFTERCARE List all medications you are taking, including prescribed & non-prescribed. Please provide the medication, dosage, reason prescribed and date of prescription. * Do you have any special needs that we should be aware of? (In need of pre-treatment housing, Learning disabilities, difficulty with reading or writing, hearing difficulties, difficulties with stairs etc.) * Are you employed? * Note: The following information is confidential for Oxford House only and will not be released. Yes No Employer's Name * If not, what is the date of your last full-time job? MM DD YYYY Will you be actively looking for work? * Yes No If you answered no, please explain Current financial assistance: * Social Services E.I. W.C.B A.I.S.H. Other I am employed If other please specify or indicate N/A if you've answered already * If you are receiving social assistance, have you received a cheque for this month? * Yes No N/A Total net monthly income * If you're not receiving social assistance, please indicate NA in the following fields Social Services Worker * If you're not receiving social assistance, please indicate NA Social Services Worker Phone * If you're not receiving social assistance, please indicate NA Past or Present Convictions, Court Dates etc., indicate N/A if this does not apply to you * Legal Status Sex related crimes? * Yes No Explain, if yes or indicate N/A if this does not apply to you * Parole or Probation Officer's name & phone # (Indicate N/A if this does not apply to you * Have you lived in Oxford House before? * Yes No If Yes, which Oxford House, when and why did you leave? If no, indicate N/A * Please provide your emergency contacts name, address and phone number * Emergency Contact Information What is your relation to them? Emergency Contact Information Parent / Family Friend Other Current Medical Condition * Recent injuries, surgery etc. Physician's name and phone * Any history and/or contact with any communicable diseases? * Yes No If yes explain, if no indicate NA * Did an agency refer you? If so please indicate which agency. * By submitting your application you agree that you have read and understand that if accepted into an Oxford House, you agree to the terms of the Resident/Oxford Tenancy Agreement. A two-week notice is required when moving from your Oxford House home. Oxford House will conduct random drug testing. The nature of Oxford House requires immediate eviction of a resident member who is using alcohol or drugs including abuse of prescription drugs. Any member suspected of using alcohol or drugs, displaying disruptive behaviour or nonpayment of monies can be evicted by a majority vote of the house membership or by Support Worker. You agree that within 72 hours (3 days) of leaving a residence, voluntarily or otherwise, you will remove your personal belongings. I understand that I am required to sign the Oxford House Rules & Regulations and the Contract of Oxford House Residency prior to moving into an Oxford House. I also understand that any false answer on any of the above items is grounds for eviction from Oxford House and I consent to the release of any confidential information regarding my personal history, medical history, treatment, and/or any information deemed necessary by the Oxford House Foundation of Canada. This authorization and request is intended confidential for the specific purposes of the Oxford House Foundation of Canada only. I agree to the terms Your message was sent successfully. Thanks.
