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New Survey: Caregiver Application


 
HEADER - Required Fields
Header Section - #FE9A2E
Year
Applicant 1 Name *
Please list last name, first name
Applicant 1 Birthdate *
Select a date from the calendar.
Applicant 2 Name
Please list last name, first name
Applicant 2 Birthdate
Select a date from the calendar.
Email Address(es) *
CEM
CEM’s (commercial electronic messages) I give consent for CSCL to send affiliated publications to the above email.
Home Address *
City *
Area *
Please indicate location of where you reside
Postal Code *
Phone *
Please indicate landline or cell and preferred number for contact.
Mailing Address (if different)
How did you hear about us? *
   
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 *
   
What style of home do you live in?
Type: *
What is the proposed living space for the Individual?
Bedroom in shared home: Details
Please check all that apply
Bedroom in shared home: Level
   
What level of the home is the bedroom on? (Main floor, upstairs, basement)
Bedroom and semi-private living space: Details
Please check all that apply
Bedroom and semi-private living space: Description
Please describe the space (eg: bedroom and TV room)
Bedroom and semi-private living space: Level
   
What level of the home is the proposed living space on?
Private Suite: Details
Please check all that apply
Private Suite: Level
What level of the home is the suite on?
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 *
Do you have a religious affiliation? This information can sometimes be useful in matching caregivers to Individuals.
Education and Experience *
Describe relevant education and professional and/or personal 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, gender, birth date, relationship, and school grade/employment
Pets *
   
Please identify if there are any pets in the home
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 of Applicants and Household Members
Header Section - #95B3D7
Health Status *
Are all family and household members in good health?
Health Issues *
Does anyone in the home have a serious, ongoing health issue, disability, or emotional or mental health issue that impacts your ability to provide care? Please note that a physician's reference is required for all caregivers.
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?
Service Type
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)
Requirements and Training *
   
Please indicate which of the following qualifications and training you have:
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 *
Please record the full address; home#, street name, city, province and postal code
Reference 1 - Telephone *
Reference 1 - email *
Reference 1 - Relationship *
What is this person's relation to you?
Reference 2 - Name *
Reference 2 - Address *
Please record the full address; home#, street name, city, province and postal code
Reference 2 - Telephone *
Reference 2 - email *
Reference 2 - Relationship *
What is this person's relation to you?
Reference 3 - Name *
Reference 3 - Address *
Please record the full address; home#, street name, city, province and postal code
Reference 3 - Telephone *
Reference 3 - email *
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. Please click "OK" to submit your record
Header - Administration Section Please Leave Blank
Header Section - #95B3D7
Reviewed?
Date Reviewed
Select a date from the calendar.
Added to Screening?
Comments
Admin/Manager Comments
View *