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: *

Month Day Year
County you are applying to provide services in: *
APPLICANT CONTACT INFORMATION
Full Name *

Last First Middle initial
Current Address *

Street Address

Street Address Line 2

City State / Province

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

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Phone Number (home)

Area Code Phone Number
Phone Number (work)

Area Code Phone Number
Preferred method of contact:
APPLICANT PERSONAL INFORMATION
Date of birth *

Month Day Year
Are you legally eligible to work in the United States? *

Yes No
EMPLOYEE OR CONTRACTOR REFERRAL
Were you referred by an employee or contractor of Child & Family Focus, Inc.

Yes No
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? *

Yes No
Are there any criminal charges against you now pending? *

Yes No
Have you ever had a restraining order issued against you? *

Yes No
Have you ever been accused/indicated for child abuse? *

Yes No
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? *

Yes No
If so, please describe the work and share what about the experience was most rewarding:
PROFESSIONAL EXPERIENCE
I am currently: *

Working full-time Working part-time Full-time student Part-time student Unemployed
Current or most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employer Phone Number

Area Code Phone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?

Yes No
Next most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employer Phone Number

Area Code Phone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?

Yes No
Next most recent employer:
Length of employment:
(From - To)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Employer Phone Number

Area Code Phone Number
Name of supervisor:
Job Title:
Job Description/Duties:
Does Child & Family Focus, Inc. have your consent to contact this employer for a reference?

Yes No
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?

Yes No
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?

Referred by CFF Employee/Contractor Referred by a family hoping to receive respite services Flyer or Brochure Career Fair/Job Fair CFF Website
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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