Nourish Families Referral Form - Childhood Connections

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

How did you hear about Nourish Families Initiative?*

Search Engine (Google, Yahoo etc)
Recommended by Friend, Family, or Colleague
Through another program at Childhood Connections
Social Media (Facebook, Instagram)

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

About the Program

Nourish Families is made up of 5-Stages that participants will engage in for a total of a year. At each step the participant will be receiving childminding during the sessions, locally made freezer meals (from our meal partners like Relvas, CrAsian and Little Hobo), fresh produce (from the Central Okanagan Food Bank and Helen’s Acres), and bread (from Okanagan Grocery), as well as child development and parenting resources from our Early Learning Toy & Resource Library. .
First time applicants will receive priority on the waitlist.

Guidelines

Family must consist of at least one parent/caregiver and at least one child under 6 years residing in the household.
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.

Consent*

I agree to the Childhood Connections privacy policy.

- The information presented in this referral is true and complete to the best of my knowledge
- I have read and agreed to the privacy policy
- Childhood Connections may contact the referral agent/family with regards to food delivery
- I have thoroughly read and understand the guidelines of Nourish Families referral program

Would you like to receive the Childhood Connections monthly newsletter?*

Yes, please!
No

Our monthly newsletter is full of information for child care providers and families alike! From library features, crafts and activities to subsidy updates and Child Care resources.

Signature

Untitled

Email

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