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701 Water Street West, Summerside, PEI
Tel: (902) 436-7576
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ASSOCIATE FAMILY PROGRAM
CAREERS
CONTACT
Request to Provide Family Care Application
REQUEST TO PROVIDE FAMILY CARE
within the Associate Family Program
Applicant's Name
*
First
Last
Co-Applicant's Name
*
First
Last
Home Phone
Cell Phone
Work Phone
Postal Code
Employment History
Present Employer
Employer's Name
Employer's Phone
Length of Employment: Start Date
MM slash DD slash YYYY
Previous Employment
Length of Employment: Start Date
MM slash DD slash YYYY
Length of Employment: End Date
MM slash DD slash YYYY
Educational Background
Education
Grade 12
Human Services Program
University
First Aid
CPR
Other Education
First Aid Expiration
MM slash DD slash YYYY
CPR Expiration
MM slash DD slash YYYY
Other Education (specify)
Volunteer Work
Other Training Courses
Comments
Spouse/Partner
Present Employer
Employer's Name
Employer's Phone
Length of Employment: Start Date
MM slash DD slash YYYY
Previous Employment
Length of Employment: Start Date
MM slash DD slash YYYY
Length of Employment: End Date
MM slash DD slash YYYY
Educational Background
Grade 12
Human Services Program
University
First Aid
CPR
Other Education
First Aid Expiration
MM slash DD slash YYYY
CPR Expiration
MM slash DD slash YYYY
Other Education (specify)
Volunteer Work
Other Training Courses
Comments
Family Dynamics
Other Members of Your Household
Please include name, gender, relationship and age
Do you babysit in your home on a regular basis?
Please list any interests/hobbies which any member of the household are willing to share with the client?
Have you discussed this application with all members of your family?
Are all members of your family supportive of your application?
Vehicle Use
Do you have a valid driver's license?
Yes
No
Does your spouse/partner have a valid driver's license?
Yes
No
Is there a car available for use?
Yes
No
Comments
Experience
Please describe any previous contact with persons with an intellectual disability/mental handicap/illness.
How do you and your family handle stressful situations? Please give three examples.
Motivation
How did you learn about the program?
State reasons for applying to this program.
