Child and Family Services of Central Manitoba

Respite Inquiry – Intake Form

If you are interested in becoming a Respite Provider, please fill out the below inquiry form and we will contact you. PDF Inquiries can be sent to cfscentral@gov.mb.ca

When completed please contact: 204-857-8751

Required fields that do not apply can be filled as ‘none’ or ‘not applicable’ (NA).

Respite Inquiry - PDF

Name (Guardian A)(Required)

Name (Guardian B)(Required)

Email (Guardian A)(Required)

Email (Guardian B)(Required)

Phone (Guardian A)(Required)

Phone (Guardian B)(Required)

Occupation (Guardian A)(Required)

Occupation (Guardian B)(Required)

Date of Birth (Guardian B)(Required)

Mailing Address(Required)

Home Address (If different from Mailing Address)(Required)

Date of Marriage or Common Law(Required)

Child A (Name and Age)(Required)

Child B (Name and Age)(Required)

Child C (Name and Age)(Required)

Child D (Name and Age)(Required)

Other Adults in Your Home (Name & Ages)

Previous Fostering Experience(Required)

Respite for what age and gender?(Required)

Time Availability(Required)

Previous Respite Experience(Required)

Additional Information(Required)

Date of Inquiry(Required)

Area of Service(Required)

Service Area: North

Service Area: South