Boarding Home Program Application

Boarding Home Program Application

This form is ONLY for Individuals Providing Homes for Boarding Students
The purpose of the Athabasca Tribal Council Boarding Home Program is to provide placement services to students attending high school in the Alberta region. The boarding home family provides room and board to a high school student. The objective is to have the student integrate with the family while being provided with residential accommodation and academic/personal support in a safe and supportive environment while the student pursues his/her high school education.

Please read the Boarding Home Program Handbook before filling out this form.

If you have any questions or concerns, please contact:

CHARLES NOKOHOO
Education Coordinator

780-791-6538 *243

charles.nokohoo@atcfn.ca
Boarding Home Program Handbook
Boarding Home Parent(s) Information
Boarding Home Parent - Primary*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number - Home*
Please enter a valid phone number.
Phone Number - Work
Please enter a valid phone number.
Phone Number - Cell
Please enter a valid phone number.
Boarding Home Parent - Secondary

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number - Home
Please enter a valid phone number.
Phone Number - Work
Please enter a valid phone number.
Phone Number - Cell
Please enter a valid phone number.
Residence Information
Type of Home*
Number of Bedrooms:*
How many other people live in the home not including Boarding Home Parents already listed?*
Name of Occupant 1

First NameLast Name
Relationship to Boarding Home Parent
Age
Name of Occupant 2

First NameLast Name
Relationship to Boarding Home Parent
Age
Name of Occupant 3

First NameLast Name
Relationship to Boarding Home Parent
Age
Name of Occupant 4

First NameLast Name
Relationship to Boarding Home Parent
Age
Name of Occupant 5

First NameLast Name
Relationship to Boarding Home Parent
Age
Name of Occupant 6

First NameLast Name
Relationship to Boarding Home Parent
Age
Do you have a student in mind to board in your home?*
Student 1

First NameLast Name
Student 2

First NameLast Name
Student 3

First NameLast Name
MANDATORY FORMS TO BE COMPLETED

To quality for entry as a Boarding Home Parent, every adult dwelling within the home must have the following two forms completed and submitted to the Education Coordinator:

1. RCMP Criminal Record Check

2. Alberta Intervention Record Check-Form CS2687

Please visit your local R.C.M.P detachment and the Athabasca Tribal Council Child and Family Services office to initiate the application process.

Room and board remuneration will not be issued until these records have been received and approved by the Education Coordinator.

Original receipts for costs associated to the clearance may be submitted to the Education Coordinator for reimbursement.

The Alberta Intervention Record Check Clearance Form will be sent to you on completion of this application.
STATEMENT OF BOARDING HOME PARENTS

As boarding home parents, I agree to the following conditions for the duration of
time the Athabasca Tribal Council high school student resides in my home:
1. To provide a home environment and standard of care that is safe, comfortable and stable.
2. To provide meals and lunches that are nutritious and well balanced.
3. To ensure the student receives prompt medical care when required and to notify the Athabasca Tribal Council and parents in the event of illness or accident.
4. To ensure to the best of my ability that the student’s physical, social, emotional, and spiritual needs are met.
5. To report to the Athabasca Tribal Council any significant behavioural or social changes in the student.
6. To allow the Athabasca Tribal Council to visit my home on a regular basis to monitor the placement and to ensure satisfactory care is being provided.
7. To provide a quiet time and place to encourage study on a regular daily basis.
8. To ensure that the student attends school each day.
9. To notify the school when the student will be absent.
10. To treat all student information provided by the school or counselors in a confidential manner.
11. In the event of an emergency, you would continue to care for boarding home students as you would your own children or family living in your household, until you transfer care and control of the child in person to their own parent/guardian.
Date Signed*

MonthDayYear
Date
Boarding Home Parent Signature*

Clear
Should be Empty:

Boarding Home Parent(s) Information

Residence Information

MANDATORY FORMS TO BE COMPLETED

STATEMENT OF BOARDING HOME PARENTS