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New Survey: Caregiver Application


 
Title *
Applicant 1 Name *
Applicant 1 Birthdate *
Select a date from the calendar.
Applicant 2 Name
Applicant 2 Birthdate
Select a date from the calendar.
Email Address(es)
Home Address
City *
Postal Code
Phone
Please indicate landline or cell and preferred number for contact.
Mailing Address (if different)
Header - Employment at CSCL
Header Section - #95B3D7
Current or Former CSCL Employee *
CSCL Employment History
If you are a current or former CSCL employee, please specify which service area, length of time you were employed and your reason for leaving.
CSCL Relation *
Are any of your household members current or former CSCL employees?
Header - Home
Header Section - #95B3D7
Type of Accommodation *
(House, Apartment, Town House, Suite, Farm, etc.)
Proposed Sleeping Arrangements
Will the individual have his/her own room? What level of the home is the room on? Describe the space.
Header - Applicant Information
Header Section - #95B3D7
Relationship of Applicants to Each Other
eg: married, brother/sister, common-law, etc. For single applicants, leave blank
Date of Marriage or Length of Common-Law Relationship
If not applicable, leave blank
Religious Denomination
Education and Experience
Describe relevant education and experience of all applicants
Header - Employment
Header Section - #95B3D7
Present Employer *
Position
Present Employer 2
Position 2
Header - Household Members
Header Section - #95B3D7
List Household Members
Please list all children, family members, and others living in home. Include name, sex, birth date, relationship, and school grade/employment
Children in Care *
Have any of your children ever been placed in foster care, or in custodial care with a relative?
Child in Care Details
If you answered "yes" to your child being in care, please specify which child, where, and when.
Family Recreation
Please list any family group and individual interests, activities, or hobbies
Header - Health History of Applicants and Household Members
Header Section - #95B3D7
Health Status
Are all family and household members in good health?
Serious Health Issues
List members who have been treated for serious health illnesses, disabilities, or long term conditions
Emotional and Mental Health
List members who have been seen or counselled for emotional or mental health problems (by psychologist, psychiatrist, social worker, or mental health clinic). Include name, professional seen by, where, and when.
Doctors Used by Family
Please list
Header - Placement Desired
Header Section - #95B3D7
Children or Adults *
Are you applying to care for children or adults?
Age range
What age range of child/adult are you wanting to provide care to?
Are you open to taking children/adults of other cultural origins?
Support Needs *
Please indicate disability you can provide care for (select all that apply):
Type of Placement Desired *
Please indicate the type of placement desired (select all that apply)
Why would you like to be a caregiver? *
Foster Parent *
Have you ever applied to foster a child?
Other Agencies *
Have you ever applied to another agency?
If Yes,
If you have ever previously applied to foster a child or applied to another agency, please indicate where and provide date(s).
Header - References
Header Section - #95B3D7
Reference 1 - Name *
Reference 1 - Address
Reference 1 - Telephone *
Reference 1 - Relationship *
What is this person's relation to you?
Reference 2 - Name *
Reference 2 - Address
Reference 2 - Telephone *
Reference 2 - Relationship *
What is this person's relation to you?
Reference 3 - Name *
Reference 3 - Address
Reference 3 - Telephone *
Reference 3 - Relationship *
What is this person's relation to you?
Signature
By checking this box, I declare that the information contained in this application is true to the best of my knowledge and that I have not omitted information requested.