New Behavioral Respite Provider Interest Behavioral Respite Provider Interest Form Applicant Name * First Name Last Name Age Cell Number (###) ### #### Email * How long have you lived at this address? Do you have a current driver's license? Yes No Do you have reliable transportation? Yes No Are you currently employed outside the home? Yes No If Yes, Where do you work and what is your job title: Do you understand that HDFS will do a criminal background check on each adult in the home? Yes No Do you smoke? Yes No What ages of children are you interested in working with? Have you ever applied to High Desert before? Yes No Have you ever been a respite or foster parent before? Yes No Are you currently certified in CPR and First Aid? Yes No What languages do you speak? Please describe in detail why you want to become a respite provider. What qualities do you possess that would make you a good respite provider? Please answer this question completely and thoughtfully. How did you hear about our agency? Internet search Facebook Instagram Peachjar/School Event-Community Booth Current Foster/Respite Parent CYFD NM Child First Network Transfer from another TFC agency Parent of Child Needing Respite HDFS Employee Other What days and times are you available to provide respite? Comment Thank you for submitting the form. We will contact you back soon.
