[CAS FORM 800]

HOMESTUDY: APPLICATION FORM

Adoption, Foster Care, Kin, Customary Care

Applicants in Ontario

Peel Children’s Aid Society

6860 Century Avenue, West Tower
Mississauga, Ontario
L5N 2W5

Ontario SAFE Documentation Package Revised - August 2011

 ADOPTION/FOSTER/KIN/CUSTOMARY CARE HOMESTUDY APPLICATION FORM

ADOPTION FOSTERING KIN CARE CUSTOMARY CARE

APPLICANT INFORMATION
APPLICANT # 1 APPLICANT # 2
Full Legal Name: Full Legal Name:
Maiden Name: Maiden Name:
Previous Names: Previous Names:
Date of Birth: Birth Date:
Birthplace: Birth Place:
Gender: Gender:
Religion: Religion:
Education: Education:
Language(s) spoken: Language(s) spoken:
Occupation: Occupation:
Employer: Employer:
Racial origin: Racial origin:
Ethnic origin: Ethnic origin:
Native Band Name/No.: Native Band Name/No.:
Citizenship: Citizenship:
Relationship of Applicants:

HOME MAILING ADDRESS

Street Address & Apt/Unit No.
City/Town: Province: Postal Code:
Home Phone: Home Fax: Home E-Mail:

CONTACT INFORMATION
APPLICANT # 1 APPLICANT # 2
Work Phone: Work Phone:
Cell Phone # : Cell Phone # :

CHILDREN
Name Gender Date of Birth Living With Whom

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OTHER ADULTS LIVING IN APPLICANT(S) HOME:

Name Gender Age Relationship to Applicant(s)

MARRIAGE or DOMESTIC PARTNERSHIP

Current Marriage Date: Current Domestic Partnership Date:
Past Marriage or Domestic Partnership - Applicant # 1 Past Marriage or Domestic Partnership - Applicant # 2
Date Begun: Date Begun:
Date Ended: Date Ended:

PREVIOUS ADOPTION/FOSTER/KINSHIP/CUSTOMARY CARE APPLICATIONS

Have you previously applied for adoption/foster/kin/customary care, either as an individual, a couple or in
a previous relationship?

□Yes □No
Have you previously began or completed an adoption/foster/kin/customary care education program?

□Yes □No
Have you previously began or completed an adoption/foster/kin/customary care homestudy assessment?

□Yes □No
Have you previously applied to adopt/foster/provide kin or customary care for a child?

□Yes □No
PREVIOUS CHILD WELFARE INVOLVEMENT

Have you previously been involved with a Children’s Aid Society or any child protection authority outside

Ontario? □Yes □No

If yes, please provide specifics:

DESIRED CHILD AND AGE RANGE

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 ADOPTION/FOSTER/KIN/CUSTOMARY CARE HOMESTUDY APPLICATION FORM

Age of Child: (or age range) _____________ Gender of Child: □Male □Female □No Preference
Race or ethnic origin of child: □Not considered Specify, if any: ________________________________

Would you consider caring for a sibling group? □Yes □No □Unsure
Would you be willing to provide care to medically fragile children or children with physical challenges?

□Yes □No □Unsure

What type of child do you feel would best adapt to your family unit and why?

Please list any significant training, experience and/or volunteer experience you have acquired.

ACKNOWLEDGEMENTS

I/We, the undersigned, submit this application with the following acknowledgements:

1. The Child Protection Information Network (CPIN) is a province-wide common information system
for all CASs in Ontario. When fully implemented in Ontario, CPIN will give workers across the
province seamless access to information they need to help keep children safe. When you inquire
about becoming a resource parent, Peel CAS will ask for your consent to enter your information
into CPIN. We are required by the Ministry of Children and Youth Services to have all case
management records be part of this new system. Privacy and confidentiality are key priorities for
CPIN. Access to information will depend on the function of a staff’s role within the agency.

2. I/We consent to the Children’s Aid Society of Peel/Adoption Agency communicating and/or
requesting information about me/us as an adult 18 years and older, to/from other children’s aid
societies, child protection authorities outside Ontario, private adoption agents/agencies, private
foster care operators, applicable government agencies or other sources as necessary.

3. I/We understand and agree that information concerning one of us individually, may be shared
by the Society with my co-applicant.

4. I/We understand that any false statement, or omitted information in this application, may
jeopardize my/our Adoption/Foster/Kin/Customary Care Application.

5. I/We understand that this application may be withdrawn by the applicant(s) or the Children’s
Aid Society of the Region of Peel at any time during the homestudy process.

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 ADOPTION/FOSTER/KIN/CUSTOMARY CARE HOMESTUDY APPLICATION FORM

6. I/We understand that the Children’s Aid Society of the Region of Peel is unable to provide
legal advice and recommends to applicants that they obtain independent legal advice
regarding adoption/fostering issues.

__________________________________ ________________________
Signature of Applicant # 1 Date

__________________________________ ________________________
Signature of Applicant # 2 Date

HOMESTUDY: FINANCIAL/EMPLOYMENT INFORMATION

Financial information is one of the factors considered in a homestudy process. It is used in assessing
the degree of financial stability and the degree of financial stress that adding a child to the family may
create. Please provide an outline of your financial situation as follows:
ANNUAL EMPLOYMENT INCOME (BEFORE TAXES) CURRENT YEAR LAST YEAR
Applicant  1    
Applicant  2    
OTHER ANNUAL INCOME- child tax credit, support, subsidies, etc. CURRENT YEAR LAST YEAR
Applicant 1
Applicant 2
TOTAL ANNUAL INCOME    

MONTHLY NET DISPOSABLE INCOME - (AFTER TAXES / DEDUCTIONS)

Applicant  1 $
Applicant  2 $
OTHER MONTHLY DISPOSABLE INCOME - PLEASE IDENTIFY
Applicant  1 $
Applicant  2 $
TOTAL MONTHLY DISPOSABLE INCOME - (A) $

MONTHLY EXPENSES AMOUNT SPENT

Mortgage / Rent $
Property Taxes $
House Insurance $
Food: home, restaurants $
Clothing $
Household Utility Bills: e.g. heat / hydro / water $
Transportation: e.g. car / bus / taxi $
$
Extra-Curricular Activities e.g. sports / fitness / memberships
$
Loan Payments: e.g. bank / personal / credit cards / Line of Credit
Other Expenses: (specify) $
TOTAL EXPENSES - (B) $
TOTAL DISPOSABLE MONTHLY INCOME REMAINING (A MINUS B) $

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 ADOPTION/FOSTER/KIN/CUSTOMARY CARE HOMESTUDY APPLICATION FORM

ASSETS VALUE
Real Estate: Home $
Real Estate: Other $
Vehicles $
RRSPs / Other Savings $
Investments: e.g. Stocks / GICs / Mutual Funds $
Bank Accounts / Cash $
Other Assets: (specify) $
TOTAL ASSETS $

LIABILITIES TOTAL AMOUNT OWED NET WORTH

Mortgage  $ Total Assets $
Bank Loans  $ Minus Total Liabilities $
Personal Loans  $ NET WORTH $
Credit Cards  $
Other Debts / Liabilities  $
TOTAL LIABILITIES  $

FOSTERING CANDIDATES ONLY: EMPLOYMENT

NAME APPLICANT 1: ____________________________________

Place of Employment: __________________________________________________________

Length of Employment: ________ Full Time  Part Time  Hours Worked Weekly _______
Typical Business Hours: Leave Home: ________________ Arrive Home: ________________
NAME APPLICANT 2: ____________________________________
Place of Employment: __________________________________________________________
Length of Employment: ________ Full Time  Part Time  Hours Worked Weekly ________
Typical Business Hours: Leave Home: ________________ Arrive Home: ________________
NOTE: When applicants are both working outside the home a Supplementary Fostering Application
Form (800-B) needs to be completed by the fostering co-parent.
 

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INSURANCE
 Life insurance policies - Amount held: 
Applicant 1:  $__________________ Applicant 2:  $_________________                            
 Identify other insurance (health, disability, etc)
Applicant 1:  ________________________________________________ 

Applicant 2:  ________________________________________________

I/We confirm that the information given on this financial statement is accurate and complete to the best
of my/our knowledge.

SIGNATURES: Applicant 1: ________________________    Date: ______________

 

Applicant 2: ________________________   Date: _______________

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