Harbor Families Application

Lifeline's Harbor Families exists to extend the hope, restoration, and the love of Jesus Christ to children and families experiencing a crisis in order to keep families together.

Through the Harbor Families ministry, local churches recruit Christ-centered host families who provide temporary, short-term care to children and church volunteers support parents working through a crisis.

The physical, emotional and spiritual supports provided through relationships with people in the body of Christ, and the tangible church and community resources are intended to prevent the need for formal services, such as involvement in the child welfare/foster care system.

Lifeline equips the church to implement the model in your community, provides assessment and training of host families and volunteers, and provides connection between vulnerable families and the church.

(WE ARE CURRENTLY OPERATING IN SIOUX FALLS, SD)

Please complete the form below to serve as your application to the Harbor Families ministry at Lifeline Children's Services.

We are honored that you have chosen us to assist you in this matter. Upon receiving your application, you will receive email confirmation that we have received your application. Should you not receive this email, please let us know at jackie.thomas@lifelinechild.org.

Region

Area affiliated with

Sioux Falls Rapid City

What Harbor Families role are you interested in participating?

Host Family/Harbor FamilyFamily Support VolunteerMinistry CaptainFamily Navigator/Coach

Harbor Families Interest

Discuss reasons for wanting to become part of the Harbor Families ministry

How did you hear about Harbor Families at Lifeline

ChurchConferenceSocial MediaFormer Safe Families connectionLifeline employeeDSSLifeline mailing list or newsletterHarbor Families volunteer

Please explain

Information Application 1

First Name

Middle

Last

Birthday

Ethnicity

E-mail address

Cell Phone Number

Street Address/P.O. Box

County

City

State

Zip

Employment

Employer

Occupation/Title

Address

Phone

Length of employment

Education Applicant 1

Please choose one

High SchoolGED

Year earned

Name of institution

College:

Degree earned:

Other:

Marriage

Marital Status:

MarriedSingle Divorced

Number years married

Spouse Name

Number of previous marriages:

Date and Location of Previous Marriage

Reason/How Terminated

Foster Care Experience Applicant 1

Are you or have you ever been a licensed foster parent

YesNo but currently taking classesNo

Current licensed state & dates

Previous licensed state & dates

Family Background Applicant 1

Discuss life experience and family relationships, general understanding of the family history & structure.

Discuss any experiences with different cultures, discrimination, and prejudice during childhood and adulthood.

Choose what best describes discipline in your family of origin

Time outsSpankingLoss of privilegesGrounding Other

If punishment was excessive Please explain:

Have any of the following occurred in your family of origin?

Domestic ViolenceChild AbuseDivorceMental Health DiseaseSubstance abuseTraumatic EventsNone

Please explain:

Legal Background Applicant 1

Have you ever been investigated for child abuse or neglect by child protective services or law enforcement?

YesNo

Have you had any child removed from your care due to abuse or neglect?

YesNo

Have you been deprived of your parental rights or had your rights restricted?

YesNo

Have you ever been arrested?

YesNo

Are you currently or previously on parole or probation for an offense?

YesNo

If yes, please explain. Include all incidents, excluding traffic violations,

References Applicant 1

Please include 3 in addition to one reference from a pastor or church leader.

1. First Name

Last

Church Relationship to applicant

E-mail address

Phone Number

2. First Name

Last

Relationship to applicant

E-mail address

Phone Number

3. First Name

Last

Relationship to applicant

E-mail address

Phone Number

4. First Name

Last

Relationship to applicant

E-mail address

Phone Number

Page 2

Applicant 2 Information

First Name

Middle

Last

Birthday

Ethnicity

E-mail address

Cell Phone Number

Street Address/P.O. Box

County

City

State

Zip

Education Applicant 2

Choose one:

High SchoolGED

Name of institution

Year earned

College:

Degree earned:

Other:

Employment

Employer

Occupation/Title

Address

Phone

Length of employment

Foster Care Experience Applicant 2

Are you or have you ever been a licensed foster parent

YesNo but currently taking classesNo

Current licensed state & dates

Previous licensed state & dates

Family Background Applicant 2

Discuss life experience and family relationships, general understanding of the family history & structure.

Discuss any experiences with different cultures, discrimination, and prejudice during childhood and adulthood.

Choose what best describes discipline in your family of origin

Time outsSpankingLoss of privilegesGrounding Other

If punishment was excessive Please explain:

Have any of the following occurred in your family of origin?

Domestic ViolenceChild AbuseDivorceMental Health DiseaseSubstance abuseTraumatic EventsNone occured

If yes please explain:

Legal Background Applicant 2

Have you ever been investigated for child abuse or neglect by child protective services or law enforcement?

YesNo

If yes, please explain.

Have you been deprived of your parental rights or had your rights restricted?

YesNo

If yes, please explain.

Have you had a child removed from your care due to abuse or neglect?

YesNo

If yes, please explain.

Have you ever been arrested?

YesNo

If yes, please explain.

Are you currently or previously on parole or probation for an offense?

YesNo

If yes, please explain.

Applicant 2 References

Please include at least one reference from a pastor or church leader

1. First Name

Last

Church relation to applicant

E-mail address

Phone Number

2. First Name

Last

Relationship to applicant

E-mail address

Phone Number

3. First Name

Last

E-mail address

Phone Number

4. First Name

Last

Relationship to applicant

E-mail address

Phone Number

Transportation

Will household vehicle be used to transport children?

YesNo

If no, then what other plans is in place for transportation of child or children?

Do applicant(s) maintain a valid driver's license and motor vehicle insurance, as required by law, on vehicles transporting families/children?

YesNo

Please list all household members approved to transport children.

Host Family understands that they are responsible for insuring that any person outside the household who transport children must have a valid driver's license, vehicle insurance and appropriate child safety seats when applicable.

YesNo

For purposes of transporting children Host Family understands that they must have appropriate child safety seats when applicable.

YesNo

Have applicant(s) had your driver's license suspended?

YesNo

Reinstated date:

We would love to know more about your relationship with Christ and about your daily walk with Him. We ask that you share your opinion(s) regarding the questions below and provide information regarding your testimony and conversion in the section that follows. Thank you for your time and willingness to share your journey to knowing Christ with us!

Religion/Spiritual Beleifs

Do you have a church family?

YesNo

Tell us a little bit about your church family

Name and address of Church

Which of the following does your family participate in?

Regular church attendance Service projects/MissionsHome Bible studiesSunday school/small groupOther church activities

Values & Beliefs

What values are important to you and or your family?

What are your family hobbies, activities and interests?

Harbor Families is about developing a relationship with the parent and the child in our care. Do you agree to this?

YesNo

Linked here is Lifeline's statement of faith made publicly available on our website. Click the link below then scroll down to read the entire "Statement of Faith" now please.

Mission and Beliefs - Lifeline Children's Services

Please check yes to affirm that you have read and agreed to Lifeline's mission and Statement of Faith

YesNo

Household Composition

List all individuals residing in the home (Please note, a full background check, including fingerprints, is required for ALL individuals over 18 residing in the home)

Name

Date of Birth

Relationship to applicant

Name

Date of Birth

Relationship to applicant

Name

Date of Birth

Relationship to applicant

Name

Date of Birth

Relationship to applicant

Home Environment

Please check all that apply

Swimming poolSwimming pool with fenceWater heater set at correct temperatureWorking smoke detectors and carbon monoxide detectorsSecured cleaning supplies and chemicalsOutlets within reach of children proctectedTrampoline with protective pads or screen

Are there any firearms in the home

YesNo

If yes please explain the purpose for being in the home, where they are stored in the home and if they are in a secured/locked container.

Do you have any pets in the home

YesNo

If yes, please check all that apply

DogCat Are they vaccinated They meet all county & city safety ordinance requirements

Financial

We understand there are going to be additional expenses and associated cost when caring for children in your home.

When considering you family's current financial status, how do you plan to sustain the associated cost that may occur while hosting children for an extended time? (additional food, clothing, travel, toys, school supplies, etc.)