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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
Driver's License *
   
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 *
   
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.
Vaccination Status *
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 *
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 *
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 *