WV Foster Parent Application

West Virginia Foster Parent Application

Please fill out every field below
Parent Name #1 *

First Name Middle Name Last Name
SS#
Parent Name #2 (If single parent, please leave blank)

First Name Middle Name Last Name
SS#
Maiden and previous married names
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Work Phone
County *
School District
Directions to Home
Previous applications of care for youth

Yes No
Agency
Date Licensed

Month Day Year
Date
Type(s) of licenses obtained
Date of withdrawal

Month Day Year
Date
Reason for withdrawal

MEMBERS OF HOUSEHOLD Include applicants, children, relatives, etc

	Last Name	First Name	Sex	Relationship Spouse, Child, etc	Birth Place and Date	School Grade Completed	Name of School/Employer

*The National Youth Advocate Program does not discriminate against in the provision of services on the basis of religion, race, color, creed, gender, gender identity/expression, sexual orientation, national origin, age, disability, ability to pay, or HIV/AIDS status.

HEALTH OF FAMILY MEMBERS
Husband’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations
Wife’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations
Child’s Name
Child’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations
Child’s Name
Child’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations
Child’s Name
Child’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations
Child’s Name
Child’s Physician
Address
Telephone
Date of last physical exam

Month Day Year
Date
Please list any special medical conditions/limitations

MONTHLY FINANCIAL STATEMENT

Sources of Income/Expenditures:
Earnings (Breakdown if more than one)
Rent/Mortgage
Pensions
Utilities
Assistance (Specify type)
Car Payment(s)
Rental Property
Transportation Costs
Other (Specify)
Groceries
Other (Specify)
Loans
Other (Specify)
Insurance (Include auto, home, health, renters, etc.)
Other (Specify)
Miscellaneous
Total
Total
Attach recent pay stub(s):

Cancel of

REFERENCES

Please list 6 references (1 can be relatives)
1. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)
2. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)
3. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)
4. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)
5. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)
6. Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship
Years you have known applicant(s)

EMPLOYMENT HISTORY
Father’s Present Employer
Occupation
Date of Employment (Month/Year)

Month Day Year
Date
Check One

Full-Time Part-Time
Previous Employer
Occupation
Dates of Employment

Month Day Year
Date
Reason(s) for Leaving
Mother’s Present Employer
Occupation
Date of Employment (Month/Year)

Month Day Year
Date
Check One

Full-Time Part-Time
Previous Employer
Occupation
Dates of Employment

Month Day Year
Date
Reason(s) for Leaving

WAIVER OF ACCESS OF RECORDS AND AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFOMRATION
I understand that the National Youth Advocate Program will not divulge any information obtained in the process of determining my compliance with all regulations covering foster parents in the State of West Virginia. I further understand that the National Youth Advocate Program will request information pertaining to my background and character. Such may involve contacting reference, creditors, neighbors and employers, past and present.

I hereby waive my right of access to any and all records of this nature and give my consent to all agencies contacted by the National Youth Advocate Program for release of information for the duration of the profile process.
Mother Signature (if applicable)

Clear
Father Signature (if applicable)

Clear
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date

Month Day Year
Date
Should be Empty: