VOLUNTARY INFORMATION. The following information may be used to select roommates based on language skills, where applicable, and for statistical purposes. Aboriginal Status: First Nations ( ) Band: Band Number: Tribal Agency: Non-Status Aboriginal person ( ) Métis ( ) Other (please specify) ( ) Languages Spoken:
VOLUNTARY INFORMATION. You may choose whether or not to provide voluntary information, and failure to provide this information will not have a negative impact on your application form. The information that is voluntary assists us in matching roommates, providing more detailed programming better suited to your needs and allows us to compile statistics as required by our funders. The Xxxxxxxxx Xxx Society of Manitoba, Inc. A United Way Member Agency House Rules for 000 Xxxxxxx Xxxxxx Housing Units These rules are an attachment to the Rental Agreement between the Xxxxxxxxx Xxx Society of Manitoba, Inc. and (tenant’s name) and form part of that binding agreement. In signing the Rental Agreement and this document, the tenant agrees to abide by these House Rules and is aware that breach of any of these House Rules or the Rental Agreement is grounds for termination of the tenancy.
VOLUNTARY INFORMATION. Upon written request of any unit member, the District shall NOT disclose the unit member’s home address, home telephone number, personal cellular phone number or personal email address to:
VOLUNTARY INFORMATION. Clients and family members often express preferences for service provider of a particular ethnic background or gender. Your completion of the information below will allow DCF to be more responsive when such a preference is requested. If you volunteer to provide the following information, it will only be used when a client or family member indicates such information is important in selecting service provider. The information collected will not be released to any other party, except in aggregate form. Ethnic background: ❑ African American/Black ❑ Asian/Pacific Islander ❑ Caucasian/White ❑ Native American/Eskimo ❑ Puerto Rican ❑ Other (not listed above) Gender: ❑ Female ❑ Male Individual Temporary Care Application rev August 2007 04-01-09 DCF Area Office Listing Chart Please indicate which DCF Area Offices you would like to receive referrals from (check all that apply). Bridgeport Danbury Hartford Manchester/Rockville Meriden Middletown Milford New Britain New Haven Norwalk Norwich Torrington Waterbury Willimantic Department of Children and Families STATEMENT OF EXPERIENCE (Must be completed by each applicant providing TEMPORARY CARE, SUPERVISED VISITATION, CHAP CASE MGMT, THERAPEUTIC SUPPORT STAFF, SUPPORT STAFF and AFTER SCHOOL Services) Name: Date of Birth: Address: City: State: Are you a Parent? □ Yes □ No How many children do you have? What are their ages? Check all that apply to your WORKING experience with children (not to include biological): I have provided babysitting or childcare: Years of Experience Occasional Babysitting Routine Scheduled Childcare □ Child age 0-2 □ □ □ Child age 3-5 □ □ □ Child age 6-12 □ □ □ Child age 13-16 □ □ □ Child age 17 and above □ □ □ Child who needs special health care or treatment:(Please specify) □ □ □ Other (Please specify): □ □ I have acted as a volunteer in the community with children and youth including: Child age 1-5 Child age 6-12 Child age 13 and above □ Youth Group □ □ □ □ Church Group □ □ □ □ Big Brothers or Big Sisters Program □ □ □ □ Youth Sports □ □ □ □ School Aide □ □ □ □ Red Cross or Other Public Health Institution □ □ □ □ YMCA Activities □ □ □ □ Reading or Storytelling □ □ □ □ Other (Please specify): □ □ □ APPLICANTS PLEASE READ AND SIGN: I certify under penalty of perjury that all the information provided is true and correct to the best of my knowledge. APPLICANT SIGNATURE: _ DATE: CERTIFICATION AND AUTHORIZATION ® DCF has contracted with Advanced Behavioral Health, Inc. (ABH ) as the credentialing ven...
