Providing safe and healthy homes for children of families in crisis.

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Host Family Application – Applicant 1

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Applicant 1 - Full Name*
List
Applicant 1 Maiden Name - if Applicable
Applicant(s) Address*
MM slash DD slash YYYY
Gender*
US Citizenship*

Hosted Children Preferences

Would you be willing to host a sibling group?*
Would you prefer hosting*

Employment

Work Status
Do you work swing/night shifts?

Relationships

Marital Status*
MM slash DD slash YYYY
If single, are you currently in a dating relationship?

Children of Applicants

Child #1 Name
MM slash DD slash YYYY
Gender
Relationship
Does this child live in your household?
Does this child attend public/private school or are they homeschooled?

Child #2 Name
MM slash DD slash YYYY
Gender
Relationship
Does this child live in your household?
Does this child attend public/private school or are they homeschooled?

Child #3 Name
MM slash DD slash YYYY
Gender
Relationship
Does this child live in your household?
Does this child attend public/private school or are they homeschooled?

Child #4 Name
MM slash DD slash YYYY
Gender
Relationship
Does this child live in your household?
Does this child attend public/private school or are they homeschooled?

Additional Information - Children living in the home

Do any minor children of the applicants have a record or pending juvenile offences?
Any behavioral concerns with any of the children living in your home?

Volunteer Experience and Community Support

Do you have any experience working or volunteering with children?*
Do you have any experience working with vulnerable children and families?*
Have you ever been a foster parent or had any interest in becoming one?
Do you have any training and/or experience working with special needs children (Autism, ADHD, ADD, etc.)*
Do you have family or friends that are supportive to you?*
Are you connected to a small group/life group?*

Home Information

Type of Residence (check all that apply)**

Do you own or rent your home?*
Do you have a pool or a hot tub? If so children must be supervised.*
Is the pool covered?
Is it fenced?
Do the adults in your home have the ability to swim to rescue?
Are there other bodies of water on the property?
If yes, are they fenced?
Are the smoke detectors and carbon monoxide detectors working?*
Is the water temperature set to avoid burning?*
Are cleaning supplies and chemicals out of reach or secured?*
Are there any open outlets, etc. that may be harmful?*
Does anyone in the household smoke?*
Note: California law prohibits smoking in a vehicle when a child is present. Safe Refuge's policy is that there is NO smoking during the hosting.
Do you have alcoholic beverages in your home or on the property that are accessible to children (such as a refrigerator or stored unlocked?)*
Does anyone on the property retain a medical marijuana prescription?*
Are there guns &/or ammunition or weapons on the property?*
If you answered yes to any of the above, please remember that must be stored away and inaccessible to children.
Do you have any pets?*

Transportation

Will household vehicles be used to transport hosted children?*
Does the applicant have a valid drivers license to operate vehicles used to transport children?*
Is there anyone in your household over 18 whom you would like to be able to transport hosted children as well?*

Applicant(s) Vehicles

Make, Model, # of passengers
Do you have proof of insurance?
Make, Model, # of passengers
Do you have proof of insurance?

Background Disclosure & Consent

Volunteers may not have engaged in or been accused or convicted of: youth and vulnerable adult abuse, indecency with a youth or vulnerable adult, or injury to a youth or vulnerable adult. All adults (over the age of 18) will be required to complete a LiveScan fingerprint clearance. If any box below is checked yes, please indicate the nature and circumstances of the original incident(s) in the space provided below. Include the date, place and the name off the individual that the incident applies to.
Have you ever been arrested, cited, convicted or currently facing charges for ANY law enforcement offense?*
.
Are you currently or previously been on parole or probation for an offense?*
Have you had any child removed from your care due to abuse or neglect?*
Have you ever been deprived of parental rights or had your rights restricted?*
Have you ever had your driver's license suspended?*
Consent*
Consent*
Consent*
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    Accepted file types: jpg, gif, pdf, png, Max. file size: 80 MB.