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Application/Solicitud: FFN Caregiver Support Network
Email
First Name
Preferred Name
Last Name
Phone Number
By providing your mobile phone number, you agree to receive a message to the provided phone number. Standard message and Data rates apply. Reply STOP to opt-out.
Zip Code
Street Address
City
State
Do you live in San José or care for a child/children who live in San José?
Yes
No
Birthdate
Ethnicity (please check all that apply)
American Indian or Alaskan Native
Black or African American
White
Asian
Native Hawaiian or Pacific Islander
Latino
Decline to state
Other
Other ethnicity
Do you identify as Hispanic?
Yes
No
What is your gender?
Female
Male
Prefer not to say
Nonbinary
Other
Other gender
Which language do you prefer to speak?
English
Spanish
Vietnamese
Other
Other Spoken Language
What is the highest level of education you have completed?
Junior High School (8th grade)
High School (12th grade)
Associate's Degree (2 years of college)
Bachelor's Degree (4 years of college)
Master's Degree or higher
Other
Other education
Have you, the caregiver, have any of the following circumstances?
Special Needs or needing special accommodations to participate in this program
Dual Language Learner
Refugee
Live in rural Santa Clara County (Gilroy or Morgan Hill)
Has experienced homelessness
Has been in foster care
Family has been impacted by domestic violence
From a family impacted by the Department of Family and Children’s Services or Family Wellness Court
Access childcare through a voucher: such as state voucher, alternative payment, or CalWorks
Native American tribal affiliation
Has served in the US Military
Do you receive alternative payments from a voucher program?
None of the above
Do you have a library card?
Yes
No
Library Card Number
How many children (ages 0-8) do you provide care for? (Including your own)
1 child
2 children
3 children
4 children
5 children
6 children
Other
Other Children
What is your relationship to the child/children you care for? Please check all that apply.
Grandparent
Aunt
Uncle
Friend
Neighbor
Babysitter or Nanny
Parent
Other
Other Relationship
Do you care for children with any of the following circumstances?
Individualized Education Plan
Special Needs
Dual Language Learners
Refugee
Live(s) in rural Santa Clara County (Gilroy or Morgan Hill)
Has experienced homelessness
Has been in foster care
Family has been impacted by domestic violence
From a family impacted by the Department of Family and Children’s Services or Family Wellness Court
Access childcare through a voucher: such as state voucher, alternative payment, or CalWorks
Native American Tribal affiliation
Someone in the child's household has served in the US Military
None of the above
Which language do you speak with the children you care for?
English
Spanish
Vietnamese
Other
Other Child Languages
Where do you provide childcare?
In my home
In the child's home
Other
Other locations
How many years and months have you been providing childcare?
Years
Months
What is the top reason you provide care for the child/children?
Bonding with the child
Helping the child's parents
Income, compensation
Other
Other Reason
What are the ages of the children you care for?
Infants (0-17 months)
0
1
2
3
4
5
Toddlers (18-36 months)
0
1
2
3
4
5
Preschool-age (36 months-kindergarten)
0
1
2
3
4
5
School-age (6 and older)
0
1
2
3
4
5
How many children of each ethnicity and/or race do you care for?
Hispanic or Latino
0
1
2
3
4
5+
American Indian or Alaskan Native
0
1
2
3
4
5+
Asian and East Asian
0
1
2
3
4
5+
Black or African American
0
1
2
3
4
5+
Native Hawaiian or Pacific Islander
0
1
2
3
4
5+
White
0
1
2
3
4
5+
More than one race
0
1
2
3
4
5+
Unknown
0
1
2
3
4
5+
Decline to state
0
1
2
3
4
5+
Do you need a computer?
Yes
No
Do you need help getting internet services?
Yes
No
How comfortable are you using a computer?
1
2
3
4
5
1 = "I am not comfortable and would like some help", 5 = "I am very comfortable . I don't need help."
How comfortable are you using the internet?
1
2
3
4
5
1 = "I am not comfortable and would like some help", 5 = "I am very comfortable . I don't need help."
How confident are you in your role as a caregiver?
1
2
3
4
5
1 = "I do not feel confident in my role as a caregiver.", 5 = "I feel very confident in my role as a caregiver."
How confident are you with your knowledge of child development?
1
2
3
4
5
1 = "I am not confident in my knowledge of child development.", 5 = "I am very confident in my knowledge of child development."
How confident are you about your knowledge of health and safety practices?
1
2
3
4
5
1 = "I am not confident in my knowledge of health and safety practices.", 5 = "I am very confident in my knowledge of health and safety practices."
Please read and check the following program requirements. Check each one to indicate that you understand and agree.
I am willing to join the TrustLine Registry for Family, Friend, and Neighbor caregivers. This will require fingerprints./ Estoy dispuesto a unirme al Registro TrustLine para cuidadores familiares, amigos y vecinos. Esto requerirá de huellas digitales.
I am committed to completing at least 21 hours of program activities. / Me comprometo a completar al menos 21 horas de actividades del programa.
I will be added to SJPL's Google Classroom so I can access program materials and information. / Seré agregado al Aula de Google de SJPL para que pueda acceder a los materiales e información del programa.
I will receive text notifications and updates from SJPL staff. I understand that SJPL staff will be using the Avochato application to text me. / Recibiré notificaciones de texto y actualizaciones del personal de SJPL. Entiendo que el personal de SJPL usará la aplicación Avochato para enviarme mensajes de texto.
I will meet with SJPL staff for 15 minutes in September 2022 to discuss my goals and progress. / Me reuniré con el personal de SJPL durante 15 minutos en septiembre de 2022 para discutir mis metas y progreso.
I will meet with SJPL staff for 15 minutes in June 2023 to discuss my goals and progress. / Me reuniré con el personal de SJPL durante 15 minutos en junio de 2023 para discutir mis metas y progreso.
I understand that the information in this application will be shared with FIRST 5 Santa Clara County. / Entiendo que la información de esta solicitud se compartirá con FIRST 5 del condado de Santa Clara.
I will join the CA ECE Workforce Registry (with SJPL staff support)
I will complete or renew my Pediatric CPR/First Aid certification (with SJPL staff support)
What do you hope to gain from this program? What is your goal? We want to help you reach it!
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