Alternative Care Application

Application to Provide an Alternative Care Home

(Restricted, Regular, Specialized)

The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Services Act (CFCS Act).

Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and / or the Freedom of Information and Protection of Privacy Act.

Any questions about the collection, use or disclosure of this information should be directed to:

The Director, Child Protection Division, (250) 387-7071, PO Box 9766. Stn. Prov Govt. Victoria, BC V8W 9S5

INSTRUCTIONS
If you cannot find enough space to include all of your responses to any of the questions on this form, please include it in the “Additional Information” section of the form. Once you have completed this form, please click the SEND button.

PART 1 - APPLICANT #1





If First Nations/ Aboriginal, please identify your cultural group or nation

Additional Information

PART 1 - APPLICANT #2





If First Nations/ Aboriginal, please identify your cultural group or nation

Additional Information

INFORMATION REGARDING CHILDREN AND EXTENDED FAMILY MEMBERS
Family Member 1

Family Member 2

Family Member 3

Family Member 4

OTHER PERSONS IN YOUR HOME
(e.g., boarders, day care children other than own children)

Other Persons 1

Other Persons 2

Other Persons 3

Other Persons 4

PART 2 - MARITAL RELATIONSHIP

Applicant #1

Applicant #2

EDUCATION AND EXPERIENCE - Applicant #1



EDUCATION AND EXPERIENCE - Applicant #2



EMPLOYMENT/OCCUPATION - Applicant #1

EMPLOYMENT/OCCUPATION - Applicant #2

YOUR OWN CHILD CARE ARRANGEMENTS

FAMILY GROUP AND INDIVIDUAL INTERESTS, ACTIVITIES, HOBBIES



HEALTH HISTORY OF APPLICANTS AND HOUSEHOLD MEMBERS
Have any of your family members been treated for serious illnesses, counseling, mental health, long-term disability?



APPLICANT #1
Have you ever applied as a caregiver home before? If "Yes" Please detail below: YesNo

APPLICANT #2
Have you ever applied as a caregiver home before? If "Yes" Please detail below: YesNo

TYPE OF CHILD FOR WHOM YOU COULD PROVIDE CARE

CHILDREN OF SPECIAL NEED
Would you care for children with special needs? If "Yes" Please detail below: YesNo

LENGTH OF PLACEMENT DESIRED

Why would you like to provide care to someone else’s children? Please comment:

YOUR HOME


Proposed Sleeping Arrangements

PART 3 - REFERENCES
Please list names and addresses of 3 references. Please include their full address with phone numbers.



DECLARATION: By ticking this box you confirm and agree to the following statement:
"I/we (the named applicants in PART1) declare that the information contained in the application is true to the best of my/our knowledge and belief and believe that I/we have not omitted any information requested."

Thank you for completing this Application.

Before you send this Application please enter the blue text in the box below.
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