Respite Provider Application Form

Respite Provider Application

Child & Family Focus, Inc. (CFF) is seeking compassionate individuals to provide care to children with behavioral health needs in Bucks, Chester, and Delaware counties. Our Respite Program provides temporary care for families who are raising a child with a mental health diagnosis. Unlike typical childcare, Respite Care is utilized to increase the wellness of the family by offering parents or other primary caregivers the opportunity to experience relief from the demands of raising a child with behavioral health needs.This is a part-time, fee-for-service, independent contractor position. Respite Services are delivered on an hourly basis in the child's home. Hours vary from week to week based on the Respite Caregiver's availability and the assigned family's needs. We value our approved Respite Caregivers! Individuals approved to provide Respite Services will receive competitive, fee-for-service compensation, after-hours on call support, and may be eligible for yearly bonuses contingent upon performance, productivity, and family feedback.
QUALIFICATIONS
- 1 to 2 years of experience
- Age groups served: Pre-school, toddler, grade school, high school
- High school degree
- 18 years or older
Refer to Application Checklist fromm the Respite Coordinator for additional qualifications and ways to obtain specific documents. Theses documents are not required when submitting an application but will be required before being contracted.
Date of application:

MonthDayYear
County you are applying to provide services in:
APPLICANT CONTACT INFORMATION
Full Name

LastFirstMiddle initial
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Number of years residing at this address:
If fewer than two years, please list previous address below.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Number of years residing in Pennsylvania:
Email Address
Phone Number (cell)

Area CodePhone Number
Phone Number (home)

Area CodePhone Number
Phone Number (work)

Area CodePhone Number
Preferred method of contact:
APPLICANT PERSONAL INFORMATION
Date of birth

MonthDayYear
Are you legally eligible to work in the United States?
EMPLOYEE OR CONTRACTOR REFERRAL
Were you referred by an employee or contractor of Child & Family Focus, Inc.
If yes, please provide their name:
CRIMINAL HISTORY
Have you ever been convicted of a criminal offense that would preclude you from working with children?
Are there any criminal charges against you now pending?
Have you ever had a restraining order issued against you?
Have you ever been accused/indicated for child abuse?
If you answered yes to any of the questions above please provide a written statement regarding the circumstances:
EDUCATION, TRAINING & OTHER RELEVANT EXPERIENCE
High School:

(Name of School or Institution)(Degree Program or Area of study)(Date of Graduation)
College or University:

(Name of School or Institution)(Degree Program or Area of study)(Date of Graduation)
Graduate Studies:

(Name of School or Institution)(Degree Program or Area of study)(Date of Graduation)
Training/Other:

(Name of School or Institution)(Degree Program or Area of study)(Date of Graduation)
How many years experience do you have working with children?
Do you have experience through volunteer work or employment in the field of Mental Heath, Intellectual Disabilities, Education, Health Care, or a related field?
If so, please describe the work and share what about the experience was most rewarding:
PROFESSIONAL EXPERIENCE
I am currently:

Other
Current or most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?
Next most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?
Next most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone Number

Area CodePhone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?
MOTIVATION
Please explain why you would like to become a Respite Provider:
Please describe how your past experiences have prepared you for your potential role as a Respite Provider:
Please list a few of your strengths that could help in the caregiver role:
In a few sentences, describe your general disciplinary philosophy:
PREVIOUS RESPITE EXPERIENCE
Have you ever been approved by another agency to provide respite or foster care?
If yes, please specify:
*Child & Family Focus, Inc. requires a written letter of reference from each agency
Dates:
(To - from)
REFERENCES
Please list two professional references and one personal reference:
1. Professional Reference
Telephone number
E-mail address
2. Professional Reference
Telephone number
E-mail address
3. Personal Reference
Telephone number
E-mail address
Where did you first hear about the Child and Family Focus Respite Provider Position?

Other
CERTIFICATION OF CONTENTS & CONSENT TO CONTACT REFERENCES
I certify that all information in this application is correct and complete, and I understand that any false statement or omission of material/fact would disqualify me from becoming approved to provide respite services. I give my consent for Child & Family Focus, Inc. to contact those individuals I have identified as professional and/or personal references.
Electronic signature
Date
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