Foster Parent Application Form

Please note that you will be required to enter 3 references at the end of this application form.

Part A: Applicant 1

Last Name*

Given Name(s)*

Also known as (including all previously used names)

Street Address*

Address Line 1 Address Line 2 City/Town Province Postal Code

Home Phone

Cell Phone

Email Address

Is the mailing address different from the street address above?

Yes

No

Mailing Address*

Address Line 1 Address Line 2 City/Town Province Postal Code

Date of Birth*

Place of Birth

Education

Are you employed?*

Yes

No

What is your place of employment?*

Occupation/Position (include schedule where applicable):*

Formal training and / or experience working with children and youth:

Any other training (first aid, suicide intervention, etc.):

Are you willing to participate in ongoing training?*

Yes

No

Have you ever been involved in any criminal activity and / or charged with a criminal offence?*

Yes

No

Please explain:*

Have you ever had or do you have any psychiatric illness?*

Yes

No

Please explain:*

Part D: Matching Children/Youth

For which age group are you interested in providing care?*

No age preference

Infant up to 2 years

2-5 years

6-11 years

12-16 years

Please explain:*

Do you have a preference for the sex of the child/youth that you are interested in providing care for? Please explain.*

Part E: References

Name three (3) references, their complete mailing and street addresses, and telephone numbers. Reference requirements include that the reference be a non-relative, have known your family for a minimum of three (3) years, and have a relationship with your family that includes in-home contact.

Reference #1

Last Name*

Given Name(s)*

Residential Address*

Street Address Address Line 2 City/Town Province Postal Code

Home Phone

Cell Phone

Email Address

Is the mailing address different from the residential address above?

Yes

No

Mailing Address*

Address Line 1 Address Line 2 City Province Postal Code

Reference #2

Last Name*

Given Name(s)*

Residential Address*

Street Address Address Line 2 City/Town Province Postal Code

Home Phone

Cell Phone

Email Address

Is the mailing address different from the residential address above?

Yes

No

Mailing Address*

Address Line 1 Address Line 2 City Province Postal Code

Reference #3

Last Name*

Given Name(s)*

Residential Address*

Street Address Address Line 2 City/Town Province Postal Code

Home Phone

Cell Phone

Email Address

Is the mailing address different from the residential address above?

Yes

No

Mailing Address*

Address Line 1 Address Line 2 City Province Postal Code

Any other information or comments you feel are important to include:

Does the individual confirm that information is complete and correct?*

Yes

No

Social Supports and Well-Being

Part A: Applicant 1

Part B: Applicant 2

Part C: Family Information

Part D: Matching Children/Youth

Part E: References