Application to be a Caregiver by HC121014072012

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									Application to be a CYF Family/Whanau Caregiver

Date




Auto populate full name of applicant 1. and Auto populate full name Applicant 2.
Auto populate postal address



Dear [Auto pop First name] and [Auto pop First name],


Re: Application to Be a Family/Whanau Caregiver

Thank you for your interest in caregiving for [insert child or young person’s name/s]. We
understand that you may wonder why you need to apply to care for your own whanau.
The reason this is important is that Child Youth and Family deals with children and
young people in vulnerable situations and we have a duty to provide them with a home
environment that can safely and appropriately meet their needs. It is important for
children and rangatahi to remain within their whanau group, so thank you for coming
forward.

Enclosed are forms to be filled out and returned to me as soon as possible so this
assessment process can begin. If you would like help to fill out the forms, please call
me, [social worker or caregiver social workers name and phone number].

In this pack you will find:
           Application form to be a Family/Whanau Caregiver
           Consent form to disclosure of information from Police
           Authorisation form for Use of Information from Child Youth and Family
           Extra Police check forms and Authorisation forms for anyone in your
            household who is aged 17 or over.

As you will see in the Application form, we need the names and phone numbers of at
least two people who can be referees for you. These need to be people who have
known you and your family for at least two years. They may be related or family friends
who know you well, or they may be a professional who also knows you. You may wish
to discuss this with them before they receive our request for information. I can phone
your referee’s or send them a form to fill in.

We will also need to talk with you about your general health, or if you prefer we can
contact your doctor directly with your written consent. Let us know if you want us to
contact your doctor and we will send this form to you.

I will contact you soon to arrange a time to visit you and your family at your home. If you
have any questions or concerns, please feel free to contact me at any time on [phone
number].

                                                                                          1
Yours sincerely,




Caregiver Social Worker/Social Worker




                                        2
 Application to be a CYF Family/Whanau Caregiver
Our assessment process starts with completion of this form which needs to be filled out by you
and your partner. Once we have your application we will contact you to discuss. Following
acceptance of the application a social worker will meet with you to find out more about yourself
and your family, including visiting your home. As part of our assessment we will also check Child,
Youth and Family and Police records and contact your referees. If you have any questions about
our assessment process, please contact us for further information.


APPLICANT 1

How are you related to the child or young person?


Your Surname or Family name:


First names:                             Preferred name


Applicant’s maiden or former name:


Date of birth:                                            Gender:

Are you known or have you ever been known by any other names than above: If so what are
these names.

Your ethnic Group:                                        Iwi Affiliation:


What is your Immigration status (e.g. Citizen, Resident, other?)


Your occupation:                                          Employer:


Your home address:


Do you rent or own your home?


Do you have household/car/other Insurance?


Previous addresses if moved in last 3 years:


Contact telephone number: (       )                       Mobile:

Are you:     Single?                  Married?            Civil Union?         Defacto?


How long have you lived together?                years    months.


If you are a SINGLE APPLICANT:
Never married/in a relationship            Separated               Divorced      Widowed


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What are the names and dates of birth of all your and/or your partner’s children? Please note
which children are living at home and which children live elsewhere.
Name                                   Date of Birth                   At home?
Name                                   Date of Birth                   At home?
Name                                   Date of Birth                   At home?



Details (names and dates of birth) of any other children or young people living in your home.

Name                                   Date of Birth

Details of other adults living in your home.



Please note that all adults in the home over the age of 17 yrs, are required to consent to Police
Check for criminal records


Are you currently or have you ever been approved as a caregiver for any other agency?
                                                                            Yes                No
If yes, give name of agency(s) and contact name


Do you currently have a child placed with you by any agency?

Religion:


Are you in good health?                                                     Yes                No


We will need to have a discussion with you about your health. Would you like your doctor to write
to us about this? (Child Youth and Family will pay)


If yes, please state doctors name and address:


Do you have a full current drivers licence? :                               Yes                No


If yes, please give details: Number                                      Expiry


If no, please provide photo ID. Type            Number                     Expiry

Have you been convicted of a driving offence that resulted in temporary or permanent loss of
licence, or imprisonment           Yes                                     No

Do you own firearms?                                                        Yes                No


If yes, please give licence and expiry date:

Have you ever had a criminal conviction?                                    Yes                No


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If “Yes” we will want to discuss this with you further. We need to know your previous convictions
so that we can assess whether there may be any potential safety concerns for children. If you
have questions about this please discuss with the social worker. Please detail:



Have you ever been involved in any violent incidents where the police have been involved?
                                                                           Yes               No
If “Yes”, please detail:


Are you awaiting sentencing or do you currently have charges pending?
                                                                           Yes               No
If “Yes”, please state the nature of the conviction/cases pending:

Have you or your children ever been involved with Child, Youth and Family in relation to any care
and protection or youth offending concerns?
(Please give details about who, when, where and why)



Have you or your family appeared in the Family Court regarding custody or guardianship matters
or disputes either in New Zealand or overseas?
If yes, please state




Please now turn to the section for BOTH APPLICANTS




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APPLICANT 2

How are you related to the child or young person?


Your Surname or Family name:


First names:                            Preferred name


Applicant’s maiden or former name:


Date of birth:                                             Gender:

Are you known or have you ever been known by any other names than above: If so what are
these names.

Your ethnic Group:                                         Iwi Affiliation:


What is your Immigration status (e.g. Citizen, Resident, other?)


Your occupation:                                           Employer:


Your home address (if different from above):


Do you rent or own your home?


Do you have household/car/other Insurance?


Previous addresses if moved in last 3 years:


Contact telephone number: (       )                        Mobile:

You do not need to repeat information given above by your partner.
However, if you live separately from your partner (Applicant 1) please state the names and
dates of birth of all your children.
Name                                  Date of Birth                     At home?
Name                                  Date of Birth                     At home?
Name                                  Date of Birth                     At home?

Details (names and dates of birth) of any other children or young people living in your home.

Name                                  Date of Birth

Details of other adults living in your home.



Please note that all adults in the home over the age of 17 yrs, are required to consent to Police
Check for criminal records

                                                                                                    6
Are you currently or have you ever been approved as a caregiver for any other agency?
                                                                           Yes                 No
If yes, give name of agency(s) and contact name
Do you currently have a child placed with you by any agency?

Religion:


Are you in good health?                                                    Yes                 No


We will need to have a discussion with you about your health. Would you like your doctor to write
to us about this? (Child Youth and Family will pay)


If yes, please state doctors name and address:


Do you have a full current drivers licence? :                              Yes                 No


If yes, please give details: Number                                    Expiry


If no, please provide photo ID. Type            Number                    Expiry

Have you been convicted of a driving offence that resulted in temporary or permanent loss of
licence, or imprisonment           Yes                                     No

Do you own firearms?                                                       Yes                 No


If yes, please give licence and expiry date:

Have you ever had a criminal conviction?                                   Yes                 No

If “Yes” we will want to discuss this with you further. We need to know your previous convictions
so that we can assess whether there may be any potential safety concerns for children. If you
have questions about this please discuss with the social worker. Please detail:



Have you ever been involved in any violent incidents where the police have been involved?
                                                                           Yes                 No
If “Yes”, please detail:


Are you awaiting sentencing or do you currently have charges pending?
                                                                           Yes                 No
If “Yes”, please state the nature of the conviction/cases pending:

Have you or your children ever been involved with Child, Youth and Family in relation to any care
and protection or youth offending concerns?
(Please give details about who, when, where and why)



                                                                                                    7
Have you or your family appeared in the Family Court regarding custody or guardianship matters
or disputes either in New Zealand or overseas?
If yes, please state




                                                                                             8
FOR BOTH APPLICANTS

When we visit you at home we will be exploring with you more detail about your family and any
experience you may have in looking after children. We will also be sharing more information with
you about how Child Youth and Family works and what this means for you being a family
caregiver for our service, as well as answering any questions you might have.
In the meantime if you want to tell us below about any particular experience, skills, abilities, or
training that you/and your partner have that will help you in caring for your whanau member you
can do so here. This also helps us identify what further support and guidance we may be able to
provide for you in caring for your family member.




Are there any particular resources or supports that you will need to help you care for the child or
young person?




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CHARACTER REFERENCES

Please provide the names and contact details of at least two people who have known you and
your partner for at least 2 years, so that we can obtain character references:

Referee (Name, Address, Phone number, email)



Referee (Name, Address, Phone number, email)




Referee (Name, Address, Phone number, email)



Additional Referee’s (Name, Address, Phone number, email)



In addition to other information provided, are there any other factors that Child, Youth and
Family should know to assess your suitability as a caregiver?



DECLARATION

The statements and answers I/we have given in this application are true and complete.



Signature of first applicant:                        Date:                    20




Signature of second applicant:                       Date:                    20

This information is being collected by Child, Youth and Family to help it in selecting people to
provide care for children and young persons in the custody of the Chief Executive. Child, Youth
and Family will hold the information provided by you, and will use it to further its statutory
obligations under the Children, Young Persons and Their Families Act, 1989.




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