Nourish Families Referral Form

• Name
  This field is for validation purposes and should be left unchanged.

• Part 1: Referral Information

• Is this a self-referral?*
  • Yes, I am referring myself or a family member
  • No, I am referring a client or family I am not related to
• Which Program are you applying for?*
  • Early Nourish Families 0- 12 months
  • Early Nourish Families 12-24 months
  • Nourish Families With Childminding
• Permissions*
  • I have express verbal/written permission from the family to submit this form on their behalf.
• Agency Name
  Please write the full name of the referring Agency
• Your Name
  First Last
• Phone
• Phone Extension
• Email

• Part 2: Family Contact Information

• Name of Applicant*
  First Last
• Address*
  Street Address City Postal Code
  This is required for our outreach workers to deliver meals and resources. Address will be confirmed before starting the program.
• Phone*
• Email*

• Part 3: Household Information

• list all household members, including the main applicant. Click the (+) button to add additional family members.

  First Name	Age/Birthdate	Allergies/Dietary Restrictions?

  Include birthdates for children under 12 years.

• Part 4: Comments

  How could this family benefit from the program? *Social/financial Barriers - medical issues – new to Canada – etc
• Please be as specific as possible*

• Part 5: Terms of Agreement
• .
• First time applicants will receive priority on the waitlist.

Guidelines

• Family must be a resident of the Central Okanagan.
• The family must face considerable financial (under $110, 000 a year), social or medical barriers. (Or equivalent life-impacting issues)
• Must participate in one of Childhood Connections Family Programs
• Incomplete referrals will not be processed.

Community Referrals

• Referral agencies with an established partnership with Childhood Connections may submit referrals.
• The parent/caregiver must give full consent for the agency to submit a referral on their behalf.
• Referrals from other agencies will be considered on a case by case bases.

Self-Referrals

• Parents/caregivers may submit a self-referral with parts 2-5 of the application.
• Self-referrals may be given different priority on the waitlist.

Privacy/confidentiality policy

• Childhood Connections respects your privacy. We never sell, trade or loan your information to any other organization. Information provided in this referral is being collected solely for the purpose of Nourish Families. The information will only be disclosed to Childhood Connections staff and Nourish Families volunteers to carry out the responsibilities of their job. Statistics are reported at the regional and provincial level; however, individuals are not personally identified in any way. By completing and submitting this application form you agree to have all collected information stored in our database system.

Signature