Caregiver Intake Form

If you are interested in becoming a Foster Caregiver please fill out the intake form below. Once you submit your intake form, we will contact you by your preferred method within 2 business days.

First Name

Last Name

Phone Number

Address

Address Line 2

City

Postal Code

Preferred Contact Method

Phone Email

Where did you hear about the need for foster caregivers? select all that apply

Family / Friend Friendship Centre TV / News Story Recruitment Material MCFD Community Radio Advertisement fosterconnection.ca Google / Search Engine Newspaper Other

Family Status

Single Married Common Law

Age Range

19-29 30-39 40-49 50+

Does Anyone in your home have Indigenous Heritage?

Yes No

What type of parenting experiene do you have

Biological Foster/Caregiver Adoptive None Other

If other, what type?

Are you Currently Parenting

Yes No

Info on children in the home (age, gender, etc.)

Info on those older than 19 in the home (relationship, etc.)

c/o Indigenous Perspectives Society: Centre of Excellence in Community Education 664 Granderson Road Langford BC Canada V9B 2R8 250.391.0007

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