Pathways Family Services
www.pathwaysfamilyservices.com
Foster Care Application
Pathways Family Services respects your privacy and we are committed to protecting all personal information submitted to us. We will only use your personal information to evaluate the appropriateness of your application as a foster home. Pathways is bound by the Freedom of Information and Protection of Privacy Act (FOIP), as well as the Personal Information Privacy Act (PIPA)
APPLICANT(S)’ INFORMATION
Date:
Primary Caregiver:
(Last) (First) (Middle)
Occupation: Number of Hours Worked per Week:
Place of Employment:
Level of Education (high school, college, university):
Telephone Numbers:
Home: Work: Cell:
Email Address:
Secondary Caregiver:
(Last) (First) (Middle)
Occupation: Number of Hours Worked per Week:
Place of Employment:
Level of Education (high school, college, university):
Telephone Numbers:
Work: Cell:
Email Address:
Current Address:
(Street) (City) (Postal Code)
Level of Foster Care you’re interested in:
Regular Foster Care Respite Care Provider
GENERAL INFORMATION
Will the Primary Caregiver noted above be working outside the home? Yes No
Are both caregivers able to attend an Orientation to Caregiver Training (24 hours total)? Yes No
Are you able and willing to attend monthly support meetings/in-services? Yes No
Do you have a vehicle available for transportation? Yes No
Do you have: a) valid driver’s license? Yes No
b) vehicle insurance with one million liability? Yes No
Second languages spoken: (Primary Caregiver):
(Secondary Caregiver):
Number of bedrooms in home/apartment:
Number of adults (18 and older) residing in your home, excluding applicants:
Number of children residing in your home: Ages:
Are there any other children with involvement in Children Services residing? Yes No
Please check all of the following that best indicates your situation:
Married Common-Law Divorced Single
With one or more dependents Without dependents
Please indicate your preference in age of child(ren) to be placed:
No preference (0 – 4) (5 – 9) (10 – 13) (14 – 17) Other:
Is your home equipped to handle a child with special needs or the requirement
of physical accommodations? (e.g. wheelchair accessible, main floor bedroom): Yes No
What will the sleeping arrangements be for any children coming into your care?
Would you accept children of a different ethnic/racial background? Yes No
Are there any restrictions for you in terms of length of stay of a child in placement? Yes No
If yes, please indicate what the restrictions are:
Do you have previous experience/training related to child care? Yes No
If so, describe:
Have you ever received services from Child Intervention Services (Children Services)? Yes No
Have you ever applied to foster before with another agency or the Regional Authority? Yes No
Can you provide a letter from a physician stating you are in good physical and
mental health? Yes No
EMPLOYMENT HISTORY
Please provide a history of your employment, starting with the most recent/current employment. If more space is required, please attach a resume.
Primary Caregiver:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
Secondary Caregiver:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
Position with Company:
Company Name: Supervisor:
Address:
Date Employed From: To:
Reason for leaving company:
PERSONAL REFERENCES
Applicants are required to provide a minimum of three (3) references, with full detail of their names and addresses. The references should be known to both applicants and one of the references must be a relative. If the applicants have a child(ren) that is/are school aged, a fourth (4th) reference is required from a school individual (teacher, principal) where the child(ren) attends.
FAMILY REFERENCE
Name of Reference:
(Last) (First) (Middle)
Address:
(Street) (City) (Postal Code)
Telephone Numbers:
Home: Work: Cell:
Number of Years Known to Applicant(s):
OTHER REFERENCES (may or may not be family members):
Name of Reference:
(Last) (First) (Middle)
Address:
(Street) (City) (Postal Code)
Telephone Numbers:
Home: Work: Cell:
Number of Years Known to Applicant(s):
Name of Reference:
(Last) (First) (Middle)
Address:
(Street) (City) (Postal Code)
Telephone Numbers:
Home: Work: Cell:
Number of Years Known to Applicant(s):
Name of Reference:
(Last) (First) (Middle)
Address:
(Street) (City) (Postal Code)
Telephone Numbers:
Home: Work: Cell:
Number of Years Known to Applicant(s):
If the applicant(s) has a school aged child(ren), a reference is required from a school individual (teacher, principal) where the child(ren) attends:
Name of School Reference:
(Last) (First) (Middle)
Position in School: Name of School:
Address:
(Street) (City) (Postal Code)
Telephone Number: Number of Years Known to Applicant(s):
I/We declare:
1. that the information contained in this application is complete and true to the best of my/our knowledge and that a false statement may disqualify my/our application from further consideration.
2. that we agree to provide Pathways Family Services with an original Intervention Record Check and an original Criminal Record Check for each applicant and all individuals residing in the home, over the age of 17 years old.
3. that Pathways Family Services is given permission to contact the references named on this application and the school where my/our children are in attendance.
4. that Pathways Family Services has permission to share this information with Child and Youth Services.
Signature of Primary Applicant Date
Signature of Secondary Applicant Date
Revised February 21, 2014