Foster Care Application Form

Foster Care Application Form

Fill out the following accurately, indicating your potential and suitability to fostering.
Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School District*

Carmichaels AreaCentral GreeneJefferson-MorganSoutheastern GreeneWest GreeneOther

Resource Parent #1
Resource Parent #1 Name*

First NameLast Name
Birth Date*

MonthDayYear
Place of Birth*
Religion/Church Affiliation*
Education: Highest Grade Completed*
Other Education
Employer*
Employer Phone Number*

Area CodePhone Number
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Position*
Hours Worked Per Week*
Length of Employment*
Years, Months
Previous Employer*
Area CodePhone Number
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Length of Employment*
Years, Months
Background:

Resource Parent #2
First NameLast Name
MonthDayYear
Place of Birth
Religion/Church Affiliation
Education: Highest Grade Completed
Other Education
Employer
Employer Phone Number

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Current Position
Hours Worked Per Week
Length of Employment
Years, Months
Previous Employer
Previous Employer Phone Number

Area CodePhone Number
Previous Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Employment

Resource Home Monthly Income and Expenses

	Income
Employment
Social Security/SSI
Unemployment Compensation
Workmen's Compensation
Veteran's Benefits
Rent/Boarders
Other
Other
Other
TOTAL

	Expenses
Mortgage/Rate
Electricity
Heat (Gas, Oil, etc.)
Water
Sewage
Telephone/Internet
Cell Phone
Homeowner's/Renter's Insurance
Car Payment(s)
Car Insurance
Car Maintenance/Gasoline
Cable TV
Life Insurance
Health Insurance or Medical/Dental Care
Food
Clothing
Miscellaneous Loan/Credit Card 1
Miscellaneous Loan/Credit Card 2
Miscellaneous Loan/Credit Card 3
Miscellaneous Loan/Credit Card 4
Other
Other
Other
Other
TOTAL

I, Resource Parent #1, certify that this statement is a correct estimate of our family income and expenses.*

Clear
Parent #1 Signature
Date*

MonthDayYear
Date
I, Resource Parent #2, certify that this statement is a correct estimate of our family income and expenses.

Clear
Parent #1 Signature
Date

MonthDayYear
Date

Verification

I/We, the undersigned, do hereby attest that neither I/we, nor any member of our household, have ever been convicted of any offense related to the abuse of children or of any violent assaultive behavior. Should the aforementioned occur at any time, I/we will immediately notify the agency.
Resource Parent #1 Signature*

Clear
Date*

MonthDayYear
Date
Resource Parent #2 Signature

Clear
Date

MonthDayYear
Date
Background Check

In accordance with Pennsylvania Act 160, Federal Bureau of Investigation (FBI) records must be conducted on individuals 18 years or older whom reside in the home. I/We authorize the release of any federal background information to Greene County Children and Youth Services. I/We understand Greene County Children and Youth Services must complete Federal Background Record checks prior to resource parent certification and as required thereafter. I/We understand the information obtained by Federal Background Record checks will be used to determine my/our initial and ongoing eligibility to be a resource parent(s) with Greene County Children and Youth Services.

Please provide the following information which is necessary to conduct a Federal Background Check
Resource Parent #1 Signature*

Clear
Date

MonthDayYear
Date
Resource Parent #1 Signature

Clear
Date

MonthDayYear
Date

Resource Parent #1
Name*

First NameMiddle NameLast Name
SSN*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth*
Country of Citizenship*
Driver's License Number*
Gender*
Height*
Weight*
Race*
Eye Color*
Hair Color*
Alias Name(s)*

Resource Parent #2
Name

First NameMiddle NameLast Name
SSN
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth
Country of Citizenship
Driver's License Number
Phone Number

Area CodePhone Number
Gender
Height
Weight
Race
Eye Color
Hair Color
Alias Name(s)

References

Please provide the name and address of four persons (three of whom are not related to you) who have known you at least three years and would be able to speak regarding your parenting abilities.
Reference 1
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation to You*
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reference 2
Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation to You*
Years Known:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
The Multiethnic Placement Act of 1994 and the amendments in the Small Business Job Protection Act of 1996, Interethnic Adoption of Multiethnic Placement Act (collectively referred to as MEPA) eliminate barriers that delay or prevent placement of child with qualified families based on ethnicity, race, or national origin. One may not delay or deny the resource or adoptive placement of a child with a qualified family, nor may one deny any person the opportunity to become a resource or adoptive parent on the basis of race, color, or national origin.
Resource Parent #1: Childhood and family background, autobiography. Please upload a PDF or Word file.*

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.pdf, .doc.docx Cancelof
Resource Parent #2: Childhood and family background, autobiography. Please upload a PDF or Word file.

Browse Files
.pdf, .doc.docx Cancelof
Resource Parent #1 Signature*

Clear
Date*

MonthDayYear
Date
Resource Parent #2 Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	YES	NO	N/A
a flush toilet?
a wash basin?
a bath or shower with hot and cold running water?
an operable heating system?
an operable telephone?
a sleeping area for children that is not an unsuitable area such as a hallway, stairway, closet, bathroom, eating area, unfinished attic or basement, garage, shed, or detached building?
separate bedrooms for children of the opposite sex who are 5 years of age or older?
a clean, comfortable mattress and clean linens, blankets, and a pillow for each child?
medication and containers of poisonous, caustic, toxic, flammable, or other dangerous materials kept in the residence distinctly marked or labeled as hazardous and all guns and hunting knives stored in locked areas inaccessible to children?
emergency telephone numbers, including those for fire, police, poison control and ambulance, conspicuously posted adjacent to all telephones?
fireplaces, fireplace inserts, and wood and coal-burning stoves and free-standing space heaters, securely screened or equipped with protective guards?
an operable smoke detector placed on each living level of the residence?
a portable fire extinguisher, suitable for Class B fires, available in the kitchen and other cooking areas and which is tested yearly or has a gauge to ensure adequate pressure?
protective safety caps placed in all electrical outlets accessible to children younger than 5 years of age?
exposed electrical wires?
potable drinking water as determined by an annual microbiological test if from a non-community source?
use of age-appropriate car seats that meet Federal Motor Vehicle Safety Standards for transporting children up to eight years of age in a motor vehicle?
insurance?
valid driver's license(s)?
valid auto inspection(s)?
pet vaccinations?
"no smoking" sign posted prominently on the main entrance to the home?