New Survey

HEADER - Required Fields

Header Section - #FE9A2E

Year *

Applicant 1 Name *

Please list last name, first name

Applicant 1 Birthdate *

Applicant 2 Name

Please list last name, first name

Applicant 2 Birthdate

Email Address(es) *

CEM

Yes

No

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? *

How did you hear about us?: Choose Option

Specify your own value:

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 *

Type of Accommodation: Choose Option

Specify your own value:

What style of home do you live in?

Type: *

Bedroom in shared home

Bedroom and semi-private living space

Private Suite

What is the proposed living space for the Individual?

Bedroom in shared home: Details

Stairs

Wheelchair Accessible

Private/own bathroom

Bed and Furniture provided

Please check all that apply

Bedroom in shared home: Level

Bedroom in shared home: Level: Choose Option

Specify your own value:

What level of the home is the bedroom on? (Main floor, upstairs, basement)

Bedroom and semi-private living space: Details

Stairs

Wheelchair Accessible

Private/Own Bathroom

Private Entry

Kitchenette

Bed and Bedroom Furniture Provided

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

Bedroom and semi-private living space: Level: Choose Option

Specify your own value:

What level of the home is the proposed living space on?

Private Suite: Details

Self-contained

Private Entry

Stairs

Wheelchair Accessible

Full Kitchen

Kitchenette/Hot Plate

Furnished

In-Suite Laundry

Shared Laundry

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

Driver's License *

Class 4

Class 5

Class 7

Specify your own value:

What type of Driver's License do you have?

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 *

Pets: Choose Option

Specify your own value:

Please identify if there are any pets in the home

Children in Care *

Yes

No

I don't have children

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.

Vaccination Status *

Fully Vaccinated (2 or more doses)

Partially Vaccinated (1 dose)

Not Vaccinated

Choose To Not Disclose Being Vaccinated

While Shared Living (HomeShare) providers are not mandated to be vaccinated, under the current orders, respite providers for adults (whether privately or through an agency) are. Further, when it comes to the matching process, some families only want to be matched to caregivers who are vaccinated. Is the primary caregiver (the person who would be in contract) in your home vaccinated for Covid 19?

Household Vaccination Status *

Fully Vaccinated (2 or more doses)

Partially Vaccinated (1 dose)

Not Vaccinated

Choose To Not Disclose Being Vaccinated

Are all household members who are eligible for vaccination (5 and up) vaccinated for Covid-19?

Vaccination Status Comments

Please feel free to provide any explanation or further information around caregiver/household vaccination status here.

Header - Placement Desired

Header Section - #95B3D7

Children or Adults *

Children

Adults

Both

Are you applying to care for children or adults?

Age range

birth - 6 yrs

6 yrs - 12 yrs

12 yrs - 18 yrs

19 yrs - 30 yrs

30 yrs - 60 yrs

60+ yrs

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?

Are you open to an individual having a pet?

Yes

No

Question for Shared Living/Homeshare only

Support Needs *

Developmental - Mild

Developmental - Moderate

Developmental - Severe

Physical - Mild

Physical - Moderate

Physical - Severe

Behavioural

Medical

Please indicate disability you can provide care for (select all that apply):

Type of Placement Desired *

Respite

Emergency/Crisis

24 hour only

Weekends

Up to 1 week

Up to 2 weeks

Longer than 2 weeks

Shared Living (full-time)

Please indicate the type of placement desired (select all that apply)

Requirements and Training *

Class V Driver's License

Computer Literacy - Basic

Computer Literacy - Experienced

First Aid/CPR Certification

Non-Violent Crisis Intervention Training

Behavioural Intervention

Positive Behaviour Supports

Personal Care

MANDT Training

None

Specify your own value:

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

Added to Screening?

Comments

Admin/Manager Comments

View *

Surveys

New Survey: Caregiver Application