Contingency Plan - Foster Home

Tennessee Department of Children's Services

Contingency Plan - Foster Home
In the unlikely event that I/we both are incapacitated, the following individuals have agreed to step in and provide care for the child(ren) placed in my/our home until such a time as the Department of Children’s Services is able to make other arrangements or I am/we are able to resume parenting responsibilities.
Foster Home Name*
Home Study Writer*
Home study writer is assigned after training is completed. If you have not completed training, please mark "Other or Unknown."
Date Completed

MonthDayYear
Date

Choice #2
Name/Relationship:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number 1
Please enter a valid phone number.
Phone Number 2
Please enter a valid phone number.
These individuals have been provided with contact information for the Department of Children’s Services and have agreed to contact the child(ren)’s Family Services Worker or Emergency On-Call immediately in the event of an emergency or my/our death(s), as soon as possible to make further arrangements.
Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Tennessee Department of Children's Services