Supported Family Networks Program – Intake FormPage 1 of 9Please complete all sections of this form. All information provided will be kept confidential and used solely for the purpose of assessing your application.Personal InformationFull NameDate of Birth*Home Address*Phone Number*Preferred Method of Contact*PhoneEmailTextGenderPlease selectHe/hisHer/hersMailing Address (if different)Email address*NextProgram InterestOur ProgramsFoster Care Program – Providing a temporary, nurturing home for children and youth unable to live with their familiesHome Share Provider Program – Offering a supportive family environment for person's served to develop life skills and build meaningful relationshipsWhich program are you applying for? (Select all that apply)*Foster Care ProgramHome Share Provider ProgramInterested in learning more about both programsWhat type of care are you interested in providing? (Select all that apply)*Full-time Foster CareRespite CareRelief CareHome ShareEmergency CareWhat age range of children or youth are you open to supporting?*0-5 years6-12 years13-19 yearsAny ageAre you open to supporting children or youth with specific needs?*YesNoOpen to learning morePlease describe any specific needs you are able to support*Where you employed before this job?*YesNoOtherPlease explain*BackNextHousehold InformationNumber of Adults (18+) residing in the home*Ages of children in the home*Number of children (under 18) residing in the home*Does anyone in the home have any medical conditions or support needs we should be aware of?NoYes (please describe type and number)Describe the medical conditions or support needs we should be aware of*BackNextHome EnvironmentDo you own or rent your home?*OwnRentOtherDo you have a spare bedroom available for a child or youth?*YesNoPlease describe the accommodation (e.g., room, suite, ground level, upstairs)*Is your home wheelchair accessible?*YesPartiallyNoIs your home safe and nurturing for children and youth?*YesNot SureNoPlease describe your home environment and any safety features:*BackNextExperience and QualificationsDo you have a valid BC Driver's Licence?*YesNoDo you have current First Aid and CPR certification?*YesNoWilling to obtainPlease describe your experience working with children and youth (include paid, volunteer, and lived experience)*Please describe any experience you have supporting individuals with complex needs (e.g., intellectual, behavioural, medical, mental health)*Do you have experience or training in any of the following? (Select all that apply)*Trauma-informed care Attachment-based practicesBehavioural supportCultural safetyMental health support Medication administrationPersonal carePositive Behaviour Support (PBS)OtherOther*Please list any relevant education, training, or certifications*BackNextCultural and Community ConnectionsDo you identify as Indigenous?*YesNoIf yes, please specify Nation/Community*What cultural traditions, practices, or languages are important in your home?*Are you committed to supporting a child or youth's connection to their culture, family, and community?*YesNoAre you open to learning about and supporting the cultural traditions and practices of the child or youth placed in your home?*YesNoBackNextMotivation and GoalsWhy are you interested in becoming a Foster Caregiver or Home Share Provider?*What strengths and skills would you bring to a child or youth in your care?*What do you hope to gain from this experience?*BackNextAdditional InformationIs there anything else you would like us to know about you or your household?*How did you hear about us?*Social MediaWebsite Friend/FamilyCommunity organizationMCFDOtherOther*BackNextConsent and DeclarationI understand that:The information provided in this form will be kept confidentialI may be required to undergo criminal record checks, home assessments, medical assessments, and reference checks as part of the application processCompletion of this form does not guarantee approval as a Foster Caregiver or Home Share ProviderI am voluntarily providing this information for the purpose of assessing my application I declare that the information provided in this form is true and complete to the best of my knowledge.Enter your full name to confirm*Confirmation Date*Thank you for your interest in joining the Jumto community. A member of our team will be in touch within 3–5 business days to discuss your application and answer any questions you may have.Together, we can create welcoming homes where children and youth feel a true sense of belonging while remaining connected to the people, cultures, and communities that shape who they are.BackSendWebsite URL*
