About
Get Help
Give Help
Donate
Contact Us
925.566.8050
Providing safe and healthy homes
for children of families in crisis.
Donate Now
Other Adults Living in the Home
Name of Safe Refuge Volunteer you reside with or frequently visit
*
What role is the volunteer(s) applying for?
*
Host Family
CoF Support Friend 2
Name
*
First
Last
Email
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Occupation or School Situation
*
Relationship
*
Parent
Friend
Renter
Purpose in the home/current situation
*
Adult Resident Background Disclosure
Other Adult Living in the Home - Not Applicants
Have you ever been arrested, cited, convicted or currently facing charges or 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 to had your rights restricted?
*
Yes
No
Have you ever had your drivers license suspended? If yes, please give the date it was reinstated.
*
Do you have a record or pending criminal offenses? If yes, please explain.
*
Transportation
Have you discussed the possibility of you driving Safe Refuge hosted children with the Host Family you are living with? If yes, please answer the following two questions.
*
Yes
No
Does the applicant(s) have a valid drivers license to operate vehicles used to transport children?
*
Yes
No
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 Driver's License and, if you are driving, a copy of your Auto Insurance Card.
Drop files here or
Select files
Max. file size: 40 MB.
Δ
Copyright © 2024 Safe Refuge for Children and Families