About
Get Help
Give Help
Donate
Contact Us
925.566.8050
Providing safe and healthy homes
for children of families in crisis.
Donate Now
Circle of Friends Application – Support Friends 2
Circle of Friends Application - Family Support 2
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone Number
Cell Phone Number
*
Email
*
Applicant 1 Date of Birth
*
MM slash DD slash YYYY
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 serving as part of the Safe Refuge a Circle of Friends?
*
Employment
Applicant 1 Occupation
*
Employer
Work Status
Full Time
Part Time
Seasonal
Contract
Other
Do you work swing/night shifts?
Yes
No
Relationships
Relationship Status
*
Married
Separated
Never Married
Divorced
Widowed
In a Dating Relationship
If married, how many times? If separated, how many times?
Date of current marriage:
MM slash DD slash YYYY
Children of Applicants who are living in the home
Child #1 Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Relationship
Biological
Adopted
Guardianship
Child #2 Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Relationship
Biological
Adopted
Guardianship
Child #3 Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Relationship
Biological
Adopted
Guardianship
Child #4 Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Relationship
Biological
Adopted
Guardianship
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 experiences with people different than your own (ethnicity, socio-economic, culture, age, etc.)
*
Do you have any training and/or experience working with special needs children (Autism, ADHD, ADD, etc.)
*
Yes
No
If yes, please describe.
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
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 these 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 be 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 Safe Refuge guidelines for transporting children.
Consent
*
I understand that I must have appropriate child safety 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
Select files
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
Select files
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
Select files
Accepted file types: jpg, gif, pdf, png, Max. file size: 40 MB.
Δ
Copyright © 2024 Safe Refuge for Children and Families