The Princess Shop - Fairy Godmother Program Application Form - Fairy Godmother
Please note that only 20 matches will be made for this year of the program. All information is used for assessing suitability for the program and for matching purposes. All personal information will be kept confidential.
CONTACT INFORMATION
Name *
Today's Date *
MM
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Email *
Home phone: *
Work: *
Cell: *
Can you be contacted at work? *
Best time to call: *
Preferred number to reach you at: *
In case of emergency who do we contact and what is your relationship to them? *
PERSONAL INFORMATION
Birth date: *
Marital status *
Do you have children *
If yes, how many boys? Ages? *
How many girls ? Ages? *
Address: *
City: *
Postal Code: *
Length of time at this address: *
How long have you lived in Saskatoon? *
Do you anticipate moving away from Saskatoon within the next year? *
Do you anticipate any changes in your life in the next year that may impact your match or your ability to commit to the program? (ie. marital status, living arrangements, employment, children, etc) *
If yes, please specify:
EMPLOYMENT INFORMATION:
Occupation: *
Employer: *
Address: *
Length of time at present employment: *
Does your work take you out of town for extended periods of time? *
BACKGROUND INFORMATION
Do you have any allergies? *
If yes, to what?
Do you have any dietary restrictions? *
If yes, what are they?
Are you taking any medications? *
If yes, please explain:
Which of the following events, if any, has occurred in your immediate family: *
Last 12 months
Anytime
N/A
Income decreased substantially
Death of immediate family member
Alcohol or drug problems
Finanical challenges
Divorce
Separation
Pregnancy
Birth of Child
Chronic Illness or Disability
Have you ever been charged or convicted of a crime? *
If yes, please explain:
Have charges of sexual abuse or physical abuse or neglect of a minor or of a vulnerable adult been founded or substantiated on you? *
If yes, please explain:
Have you been treated for alcohol or chemical abuse? *
If yes, please state length of sobriety:
Do you smoke? *
Would you consider being matched with a Princess Graduate who smokes? *
What do you consider to be the major areas of concern in your life at this time? *
How do you deal with these stresses? *
Is there any family history of chemical dependency/alcoholism, physical, sexual, or emotional abuse; or any mental health issues? *
If yes, please describe:
Do you have a learning disability? *
If yes, what is it:
What people, if any, are currently assisting you in coping with issues you described in questions 9-11? Include: Name and Relationship /Capacity *
ADDITIONAL INFORMATION:
Why do you want to become a Fairy Godmother? *
What aspects of Fairy Godmother program interest you the most? *
How did you hear about this program? *
Please list any clubs or organizations of which you are a member *
Have you served as a volunteer in the past five years? *
If yes, where did you serve:
What type of work were you doing as a volunteer?
What do you bring to the program? What experience and /or gifts would to share with your Princess Graduate? *
What would you like to gain from the program? *
Describe what role, if any, religion/spirituality plays in your life. How do you see sharing these beliefs in your match relationships? *
With what type of Princess would you like to be matched? (Describe specific attributes you prefer) *
What are your concerns or questions about working with a Princess Graduate? *
What would you like your Princess Graduate to know about you ? *
Activities/interests/hobbies/sports you enjoy: *
What would you like to know about your Princess Graduate? *
REFERENCES
All of the references must have known you for two years. References that can attest to your experience working with youth are beneficial. Each one will be contacted to ask for information regarding your suitability to act as a volunteer mentor. References cannot be your spouse, girlfriend/boyfriend or partner.
Name: *
Title: *
Address: *
City: *
Postal Code: *
Email: *
Phone: *
Name: *
Title: *
Address: *
City: *
Postal Code *
Email: *
Phone: *
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