Host Family Application – Applicant 1 – Safe Refuge for Children and Families

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

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Host Family Application – Applicant 1

Applicant 1 - Full Name*
First Middle Last
Applicant 1 Maiden Name - if Applicable
Last
Applicant(s) Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Cell Phone Number*
Email*
Applicant 1 Date of Birth*
MM slash DD slash YYYY
Applicant 1 Place of Birth*
Gender*
- Male
- Female
Applicant 1 Ethnicity*
Applicant 1 Religion*
Applicant 1 Church*
How long have you been attending this church?
Applicant 1 Languages*
US Citizenship*
- Yes
- No
- Legal Resident
How did you hear about Safe Refuge for Children and Families?*
Why are you interested in becoming a Safe Refuge Host Family?*
Hosted Children Preferences
Would you be willing to host a sibling group?*
- Yes
- No
If yes, how many children would your family be comfortable hosting?*
What is your age range preference (between 0 - 17)?*
Would you prefer hosting*
- Boys
- Girls
- No Preference
Employment
Applicant 1 Occupation*
Employer Name and Address
Work Status
- Full Time
- Part Time
- Seasonal
- Contract
- Other
Do you work swing/night shifts?
- Yes
- No
Relationships
Marital Status*
- Married
- Separated
- Never Married
- Divorced
- Widowed
If married, how many times? If separated, how many times?
Date of current marriage:
MM slash DD slash YYYY
If single, are you currently in a dating relationship?
- Yes
- No
Children of Applicants
Child #1 Name
First Last
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Relationship
- Biological
- Adopted
- Guardianship
Does this child live in your household?
- Yes
- No
Does this child attend public/private school or are they homeschooled?
- Public/Private
- Homeschool
- Not Applicable
Child #2 Name
First Last
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Relationship
- Biological
- Adopted
- Guardianship
Does this child live in your household?
- Yes
- No
Does this child attend public/private school or are they homeschooled?
- Public/Private
- Homeschool
- Not Applicable
Child #3 Name
First Last
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Relationship
- Biological
- Adopted
- Guardianship
Does this child live in your household?
- Yes
- No
Does this child attend public/private school or are they homeschooled?
- Public/Private
- Homeschool
- Not Applicable
Child #4 Name
First Last
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Relationship
- Biological
- Adopted
- Guardianship
Does this child live in your household?
- Yes
- No
Does this child attend public/private school or are they homeschooled?
- Public/Private
- Homeschool
- Not Applicable
Additional Information - Children living in the home
Do any minor children of the applicants have a record or pending juvenile offences?
- Yes
- No
If yes, please explain:
Any behavioral concerns with any of the children living in your home?
- Yes
- No
If yes, please explain:
Volunteer Experience and Community Support
Do you have any experience working or volunteering with children?*
- Yes
- No
If yes, please elaborate:
Do you have any experience working with vulnerable children and families?*
- Yes
- No
If yes, please elaborate:
Have you ever been a foster parent or had any interest in becoming one?
- I have been a foster parent.
- I am currently a foster parent.
- I am interested in becoming a foster parent.
- None
If yes, please elaborate:
What areas are you CURRENTLY serving in (church and/or community)?*
What other areas of volunteer work have you been involved with in the PAST?*
Please share your experience with groups different than your own (ethnicity, socio-economic, culture, etc.)*
Do you have any training and/or experience working with special needs children (Autism, ADHD, ADD, etc.)*
- Yes
- No
If yes, please describe.
Do you have family or friends that are supportive to you?*
- Yes
- No
If yes, tell us a little bit about your support community.
Are you connected to a small group/life group?*
- Yes
- No
Home Information
Type of Residence (check all that apply)**
- Single Family Home
- Duplex
- Condominium
- Apartment
- Military
- Mobile Home
- One Story
- Two or more Stories
- Basement
- Bi-Level
Do you own or rent your home?*
- Rent
- Own
Number of Bedrooms*
Number of Bathrooms*
Number of available EXTRA bedrooms or beds for Safe Refuge hosted children*
Is there any type of business operated from the residence? If yes, describe what type of business it is and what impact it would have during a Safe Refuge Hosting:
Do you have a pool or a hot tub? If so children must be supervised.*
- Yes
- No
Is the pool covered?
- Yes
- No
Is it fenced?
- Yes
- No
Do the adults in your home have the ability to swim to rescue?
- Yes
- No
List any other safety precautions you have in place in regards to the pool/hot tub:
Are there other bodies of water on the property?
- Yes
- No
If yes, are they fenced?
- Yes
- No
Are the smoke detectors and carbon monoxide detectors working?*
- Yes
- No
Is the water temperature set to avoid burning?*
- Yes
- No
Are cleaning supplies and chemicals out of reach or secured?*
- Yes
- No
Are there any open outlets, etc. that may be harmful?*
- Yes
- No
Does anyone in the household smoke?*
- Yes
- No
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?)*
- Yes
- No
Does anyone on the property retain a medical marijuana prescription?*
- Yes
- No
Are there guns &/or ammunition or weapons on the property?*
- Yes
- No
If yes, how and where are they stored?
If you answered yes to any of the above, please remember that must be stored away and inaccessible to children.
- I understand that alcoholic beverages, medical marijuana, guns & ammunition, and any medications must be stored away and inaccessible to children.
Do you have any pets?*
- Yes
- No
If yes, please list them and note: type, breed, if they are child friendly, vaccinated, and any other comments.
Insurance Requirement
Safe Refuge Host Families are required to have a minimum of $1,000,000 in Umbrella Liability Coverage OR Have a minimum of $1,000,000 in Homeowners or Renters Insurance. At the end of the application you will be asked to upload Evidence of Insurance for one of the options above.
I have*
- a minimum of $1,000,000 in Umbrella Liability Coverage
- a minimum of $1,000,000 in Homeowners or Renters Insurance
Transportation
Will household vehicles be used to transport hosted children?*
- Yes
- No
Does the applicant have a valid drivers license to operate vehicles used to transport children?*
- Yes
- No
Is there anyone in your household over 18 whom you would like to be able to transport hosted children as well?*
- Yes
- No
If yes, please list their name.
Applicant(s) Vehicles
Vehicle #1

Make, Model, # of passengers
Do you have proof of insurance?
- Yes
- No
Vehicle #2

Make, Model, # of passengers
Do you have proof of insurance?
- Yes
- No
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.
Do you use drugs/alcohol/marijuana? If so, what? How much? How often?*
Have you ever been arrested, cited, convicted or currently facing charges for ANY law enforcement offense?*
.
- Yes
- No
Are you currently or previously been on parole or probation for an offense?*
- Yes
- No
Have you had any child removed from your care due to abuse or neglect?*
- Yes
- No
Have you ever been deprived of parental rights or had your rights restricted?*
- Yes
- No
Have you ever had your driver's license suspended?*
- Yes
- No
If yes, when was your license reinstated?
Please provide the nature and circumstances of any "yes" incidents indicated above:
Consent*
I understand that all drivers must hold a valid drivers license and provide proof of insurance before transporting minors in my care and must adhere to the Safe Refuge guidelines for transporting children.
Consent*
I understand that I must have appropriate car seats when applicable. (Home church or Safe Refuge staff can assist with providing car seats.)
Consent*
I agree that the above information is true to the best of my ability.
Please sign your name and today's date
Please upload a photo of your CA Drivers License.
Drop files here or

Accepted file types: jpg, gif, pdf, png, Max. file size: 40 MB.
Please upload a photo of your Auto Insurance Card.
Drop files here or

Accepted file types: jpg, gif, pdf, png, Max. file size: 40 MB.
Please upload a photo of your Homeowners, Renters or Umbrella Insurance.
Drop files here or

Accepted file types: jpg, gif, pdf, png, Max. file size: 40 MB.

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Safe Refuge for Children + Families

25A Crescent Drive, #337
Pleasant Hill, CA 94523
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Providing safe and healthy homes for children of families in crisis.

Host Family Application – Applicant 1

Hosted Children Preferences

Employment

Relationships

Children of Applicants

Additional Information - Children living in the home

Volunteer Experience and Community Support

Home Information

Insurance Requirement

Transportation

Applicant(s) Vehicles

Background Disclosure & Consent

Safe Refuge for Children + Families

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