FOSTER CARE INQUIRY
INTEREST:
adoption
legal risk
foster
respite
other/not sure
COUNTY OF RESIDENCE
Parent 1:
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
OTHER NAMES USED
DOB
Parent 2:
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
OTHER NAMES USED
DOB
DATE MARRIED
/
Month
/
Day
Year
Date
DATE DIVORCED (if applicable)
/
Month
/
Day
Year
Date
ADDRESS
CITY
ZIP
Have you lived in another state in the last 5 years?
yes
no
PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
EMPLOYER - Parent 1
years
EMPLOYER - Parent 2
years
List all other members of the household. Include their name, date of birth, relationship to you, gender, and SSN.
If you have other children living outside of the household, list them here. Include their name, date of birth, relationship to you, and gender.
DO YOU PROVIDE DAYCARE, WHETHER LICENSED OR UNLICENSED?
yes
no
Have you been a Resource Parent in the past?
yes
no
Have you ever applied to be a Resource Parent?
yes
no
OTHER SOURCES OF INCOME TO THE HOUSEHOLD
Do any members of your current household have a criminal record?
yes
no
If yes, explain:
Have any members of your household been accused of harming children?
yes
no
If yes, explain:
How did you hear about our programs?
If you are interested in becoming licensed for specific children (kinship), please list their name, age, gender, and relationship to you.
PREFERENCES:
age range
number of children
gender
male
female
both/either
siblings
yes
no
How soon will you be available for training?
COMMENTS/ADDITIONAL INFORMATION
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Submit
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