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RESIDENTIAL PROGRAM – ADMISSION PACKAGE

Mission Statement Columbus House seeks to improve the quality of life for youth in Renfrew County by providing structured, supportive, safe residential and day programs in a Christian environment while pursuing their education and training.

We believe that we can not make it Alone in Life … so as we travel this Journey together we make the following Commitments as a group …          

To Respect Others and Their Property in our Daily Interactions To Help Foster a Healthy Living Environment through Positive Attitudes To Attend School and make a Consistent Effort each day To Work Together to Overcome the Challenges in our lives To Learn to Communicate in Speech and Writing To Assist our Community by Participating in Voluntary Activities To Uphold Everyone’s Right to Confidentiality To Help in the Development of Personal Independence To Support each other in Making Healthy Personal Choices through Listening and Discussing To Recognize and Celebrate that we are All Individuals with a Variety of Backgrounds and Life Experiences

ADMISSION PROCEDURE 1. THE YOUTH MUST REVIEW & COMPLETE THIS PACKAGE 2. CONTACT THE RESIDENTIAL PROGRAM SUPERVISOR TO SCHEDULE AN INTAKE INTERVIEW **THE YOUTH MUST CONTACT US TO REQUEST THIS MEETING AS THIS IS A VOLUNTARY PROGRAM (613 732-2791 OR 613 732-8977) 3. PLEASE BRING THE COMPLETED PACKAGE WITH YOU TO THE INTERVIEW

www.columbushouse.ca * Telephone (613)732-8977/732-2791 P.O. Box 1311 Pembroke, Ontario K8A 6Y6


Columbus House (Pembroke) Inc. P.O Box 1311 Pembroke, Ontario K8A 6Y6 ______________________________________________________________________________ Location: Girls’ Residence – 278 Nelson Street 613 732-8977 Boys’ Residence – 542 River Road 613 732-2791

Capacity: Accommodations for 14 people (7 per residence)

Clientele: Young men and women who are:      

Between the ages of 16 and 21 yrs Interested in continuing/completing their high school education Without shelter Unable to live with their family Without security, stability, support and guidance Wards of Family and Children’s Services

Length of Stay: According to the needs of each individual

Objectives of the Program: To provide homeless young people with a residential facility and to assist them in becoming self-supporting and responsible citizens

Program Highlights:    

Provide 24-hour supervision while in residence Provide informal counseling & make referrals when needed Encourage continued education or aid in finding employment Provide guidance and assistance in learning the basic skills of household management, budgeting, cleaning, food preparation and nutrition  Provide a full life skills program with the goal of independent living Staff: Columbus House is administered by an Executive Director and is staffed 24 hours per day


HOUSE GUIDELINES AND POLICIES House Routine: A typical weekday at Columbus House begins with a wake up call at 7am. Residents are responsible to make their own breakfast & lunch. All residents leave for school no later than 7:45am. Residents are due back at the residence by 4:30pm (4pm if it is your cook night) and everyone has dinner together at 5pm. After dinner you are on your own to go out or have friends in. If it is your room & laundry night you will need to do this before going out. Thursday night is chore night after dinner and every resident is responsible to clean one of the common areas on the main floor. All residents are expected home by curfew. After 3 weekends in the program, any resident can request weekends away by completing a request form and staff will confirm the plans. ** School is the number one priority. All residents are expected to attend all of their classes each day and they are encouraged to achieve their high school credits to the best of their ability. Monthly school reports provide updates from teachers. Work. As we are assisting residents to work toward independent living, all residents will receive support from staff within the first couple of months to secure part-time employment throughout the year. Volunteer Work is an important part of the program, and all residents will be expected to participate during their time at Columbus House. Smoking is not permitted in any of the Columbus House buildings. Weapons are not allowed on the property. Alcohol and Drugs are not permitted on the property. Any substances will be removed and the resident(s) responsible will find their placement at risk. House medications (ie. Tylenol, etc.), firstaid kit and any medications belonging to residents will be kept in the staff office. Foul Language and Physical Aggression is not acceptable, nor is disrespect to any other resident or staff member. Room and Board. Monthly payment of room and board will be made at the beginning of each month, according to a pre-determined arrangement. Hygiene and Appearance. All residents are expected to maintain a neat and tidy appearance. House Responsibilities. As Columbus House is now your home, you are expected to actively participate in the upkeep of the house. House responsibilities will be shared and posted each week. Laundry. Each resident is responsible for their own laundry. All residents will receive assistance from staff on the use of the laundry facilities. All laundry is to be completed before 10:30pm on your assigned night.


Personal Needs. Residents are expected to purchase their own deodorant, toothpaste, shampoo and other personal needs. Safekeeping. Please consult the staff about safekeeping. A lock box or locked closet is also available in your room. Columbus House is not responsible for lost, stolen or damaged property. Cell Phones. Can be used in the residence however, there is a time and place for everything. Cell phones are not allowed at the dinner table, during a house meeting or meeting with staff or at volunteer work activities.

Curfew. From Sunday to Thursday, all residents over 16 years of age are required to be in the house by 10:15pm. On Friday and Saturday nights, all residents are to be in by 11:45pm. Residents under 16 must be in the house by 9:00pm on school nights, and 11pm on the weekends. Meals. Residents prepare their own breakfast and lunch each day. All residents must attend dinner unless they are working or participating in a school related activity. Visitors. Are welcome from noon-4pm and after dinner from 7pm-10:15pm during the week and from noon-11:45pm on Fridays & Saturdays. Visitors are allowed in the lounge, living Room and yard areas. No visitors are allowed on the second floor.

 Staff must be made aware of any appointments, commitments and/or work schedule  Responsibilities must be completed and checked by staff before leaving for the weekend.  Outside behavior – no yelling or loud music. Please be aware of common courtesies to extend to our neighbors!


APPLICANTS …. * PLEASE HAVE YOUR CURRENT TEACHERS COMPLETE THIS FORM * BRING THE COMPLETED FORM WITH YOU TO YOUR INTAKE INTERVIEW MONTHLY SCHOOL REPORT Student’s Name: ___________________________________________ Month: __________________ Period A Course Name: ____________________________ Teacher: ___________________________ Absences for the Month: ____________________________ Lates for the Month: ________________ Any Assignments that are past due? ______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Period B Course Name: ____________________________ Teacher: ___________________________ Absences for the Month: ____________________________ Lates for the Month: ________________ Any Assignments that are past due? ______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Period C Course Name: ____________________________ Teacher: ___________________________ Absences for the Month: ____________________________ Lates for the Month: ________________ Any Assignments that are past due? ______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Period D Course Name: ____________________________ Teacher: ___________________________ Absences for the Month: ____________________________ Lates for the Month: ________________ Any Assignments that are past due? ______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________


Parent Questionnaire These questions will help us to learn more about your Family 1. The things I like most about my child(ren) are:

2. My life would really be better six months from now if: _____________________________________________________________________________________

3. My child’s/children’s life would really be better six months from now if: _____________________________________________________________________________________

4. The best times we have had as a family are:

6. What activities does your family enjoy?


7. What are your family traditions or important cultural events?

_____________________________________________________________________________________

These next questions will help us to get to know your Child better. Please circle Yes or No for each question and feel free to add any additional comments in the space provided.

Do you notice that your child ‌ 1. Demonstrates a sense of belonging to family?

2. Is self-confident?

Y or N

3. Acknowledges painful feelings? Y or N

4. Maintains positive family relationships? Y or N

5. Demonstrates a sense of humor? Y or N

Y or N


6. Asks for help? Y or N

7. Expresses remorse for behavior that hurts or upsets others?

Y or N

8. Shows concern for the feelings of others? Y or N

9. Completes a task on first request? Y or N ____________________________________________________________________________________

10. Requests support from peers and friends? Y or N

11. Discusses problems with others?

Y or N

12. Identifies personal strengths? Y or N

13. Interacts positively with siblings? Y or N


14. Is enthusiastic about life?

Y or N

15. Respects the rights of others? Y or N

16. Talks about the positive aspects of life? Y or N

17. Attends school regularly? Y or N

18. Uses appropriate language? Y or N

19. Can name one career or life goal?

Y or N

20. Has a specific vocational skill? Y or N

_____________________________________________________________________________________


Youth Questionnaire

As a young person we understand that it is important to have ‘a voice’ concerning the decisions that affect your life… These questions will help us to learn more about your Family

1. My life would really be better six months from now if:

2. The most important thing I have ever done is:

3. I am happiest when:

4. The best times we have had as a family are:


5. Name some special rules that your family has:

6. Who are the people you call when you need and want to talk?

7. What activities does your family enjoy?

8. Are there any special values or beliefs that were taught to you by your parents or others who are or have been important to you?


These next questions will help us to know You better. Please circle Yes or No for each question and feel free to add any additional comments in the space provided.

1. My family makes me feel wanted? Y or N

________________________________________________________________________

2. I trust at least one person very much? Y or N

________________________________________________________________________

3. I let someone know when my feeling are hurt? Y or N

________________________________________________________________________

4. I get along well with my family? Y or N

________________________________________________________________________

5. I ask for help when needed? Y or N

________________________________________________________________________

6. My parents and I talk about how I act at home? Y or N

________________________________________________________________________


7. I care about how others feel? Y or N

________________________________________________________________________

8. I think about what could happen before I decide to do something?

Y or N

________________________________________________________________________

9. I go to religious activities? Y or N

________________________________________________________________________

10. I ask my friends for help? Y or N

________________________________________________________________________

11. When I have a problem, I talk to others about it?

Y or N

________________________________________________________________________

12. I do my school work on time? Y or N

________________________________________________________________________


13. I know when I am happy and when I am sad? Y or N

________________________________________________________________________

14. I know what I do well?

Y or N

________________________________________________________________________

15. I accept responsibility for my actions? Y or N

________________________________________________________________________

16. I get along with my brothers and sisters? Y or N

________________________________________________________________________

17. I pay attention in class? Y or N

________________________________________________________________________

18. I use appropriate language? Y or N

________________________________________________________________________


19. I attend school daily? Y or N

________________________________________________________________________

20. I can name at least one thing that I want to do in my life? Y or N

________________________________________________________________________

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1. My favorite hobbies or activities are: _______________________________________

________________________________________________________________________

________________________________________________________________________

2. The most important people in my life are: ___________________________________

________________________________________________________________________

3. The best thing about me is: ______________________________________________

________________________________________________________________________

________________________________________________________________________


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