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Circle of Friends – 2nd Adult in the Home
Family Support 2
Applicant 2 - Full Name
*
First
Middle
Last
Applicant 2 Maiden Name - if Applicable
Last
Home Phone Number
Cell Phone Number
*
Email
*
Applicant 2 Date of Birth
*
MM slash DD slash YYYY
Applicant 2 Place of Birth
*
Applicant 2 Gender
*
Male
Female
Applicant 2 Ethnicity
*
Applicant 2 Religion
*
Applicant 2 Church
*
How long have you been attending this church?
Applicant 2 Languages
*
US Citizenship
*
Yes
No
Legal Resident
How did you hear about Safe Refuge for Children + Families?
*
Why are you interested in becoming a Safe Refuge host family?
*
Employment
Applicant 2 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?
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.
What others areas of volunteer work have you been involved with in the PAST?
Do you have any training or experience working with special needs children?
*
Yes
No
If yes, please describe.
Background Disclosure & Consent
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 license and provide proof of insurance before transporting minors in my care.
Consent
*
I understand that I must have appropriate child safety seats when applicable.
Consent
*
I understand that I am responsible for ensuring that any person outside the household who transports children must have a valid drivers license and insurance and must adhere to the Safe Refuge guidelines for transporting children.
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. and Auto Insurance Card.
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