Family Coach Application

Applicants Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Maiden Name

First Last

Primary Phone*

Secondary Phone

Primary Email*

Date of Birth*

Birth Place*

Gender*

Male
Female

Relationship Status*

Ethnicity*

Religion*

Church

How long have you attended this church?

Languages

Occupation

Employer Name

Employers Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

US Citizen*

Yes
No

Legal Resident*

Yes
No

How did you hear about Safe Refuge for Children + Families?*

Why are you interested in becoming a Family Coach?*

Personal Assessment

When thinking of the Family Coach Ministry, what will your strengths be? What do you think might be challenging for you?*

Please describe a time in your life that you have experienced significant loss.*

Check the boxes that best describe your parents’/primary caretakers’ relationship with each other when you were a child:*

Are there issues, traumatic incidents, or accidents from your childhood that currently cause you distress?*

Have you ever required counseling or psychiatric care? If yes, briefly explain.

Describe your religious beliefs.*

How many hours a week could you commit to being a Family Coach for Safe Refuge for Children + Families?*

Educational History

Please check the highest level of education that you have completed.*

Less that High School
High School/GED
Some College
2 year degree (AA, AS)
4 year degree (BS, BA)
Master’s Degree
Doctoral
Professional (MD, JD)

High School

Name, Location, Dates Attended

Additional Education

Name, Location, Dates Attended, Major, Degree

College

Name, Location, Dates Attended, Major, Degree

Applicant Disclosure

Have you ever been arrested, cited, convicted, or currently facing charges for ANY law enforcement violation/offense?*

Yes
No

Are you currently or previously 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

Habe you ever been deprived of parental rights or had your rights restricted?*

Yes
No

Drivers License/ID Number*

Have you ever had your drivers license suspended?*

Yes
No

If yes, what date was your license reinstated?

Do you use drugs, alcohol &/or marijuana? If yes, how much and how often?*

Transportation

Do you plan on transporting host children?*

Yes
No

Do you have a valid drivers license to operate vehicles to transport children?*

Yes
No

If no, please explain:

Household Vehicles: Make, Model and # of passengers

Do you have proof of insurance?

Yes
No

Household Vehicles: Make, Model and # of passengers

Do you have proof of insurance?

Yes
No

Do you have extra car seats?*

Yes
No

Do you have extra booster seats?*

Yes
No

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 will be asked for a DMV printout.

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 Safe Refuge guidelines for transporting children.

Date*

Household Composition

Name

First Last

Date of Birth

Resides

Part Time
Full Time

Relationship to Applicant

Spouse, child, foster child, adopted child, Godchild, step child, etc.

Name

First Last

Date of Birth

Resides

Part Time
Full Time

Relationship to Applicant

Spouse, child, foster child, adopted child, Godchild, step child, etc.

Name

First Last

Date of Birth

Resides

Part Time
Full Time

Relationship to Applicant

Spouse, child, foster child, adopted child, Godchild, step child, etc.

Name

First Last

Date of Birth

Resides

Full Time
Part Time

Relationship to Applicant

Spouse, child, foster child, adopted child, Godchild, step child, etc.

References

Please provide two personal and one pastoral reference. Please have them complete the online form or print it and have them send it to:

Safe Refuge for Children & Families 25A Crescent Drive, #337 Pleasant Hill, CA 94523

Pastor or Elder Name*

First Last

Email

Name*

First Last

Email

Name*

First Last

Email

Consent*

I agree that the above information is true to the best of my ability.

Email*

Date*

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