Foster Parent Application

Foster Parent Application
Applicant 1 Information
Name*

First NameLast Name
Former Names (Maiden, Former Married Names, Aliases, etc.)
Date of Birth*

MonthDayYear
Date
Social Security #
Do you have a valid NM driver's license?*

YesNo
Driver's License Number*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different than your physical address?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment Information

Occupation: (Previous 3 Years)
Are you a US Citizen or authorized to work in the US?*

YesNo
Have you previously worked for Childhaven*

YesNo
Are you currently employed?*

YesNo
1. Current Employer/Title
Position Title
Start Date
Reason for Leaving
May we contact your current employer?*

YesNo
Contact Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
2. Previous Employer/Title
Position Title
Start Date
End Date
Reason for Leaving
May we contact your previous employer?

YesNo
Contact Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
3. Previous Employer/Title
Position Title
Start Date
End Date
Reason for Leaving
May we contact your previous employer?

YesNo
Contact Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
If more than three employers in the past three years, please list information here:
Education
Highest Education Level Completed
Location of School (City and State)
Please list any additional languages that you speak fluently:
Medical History
Present Medical Conditions*
Past Medical Conditions*
Hospitalizations*
Current Medications*
Marriage/Significant Adult Interpersonal Relationships
Relationship Status*
Other*
Marriage Date*
Divorce Date*
Date of Significant Other's Death*
State of Relationship (Location)*
Do you have any other prior marital relationships*

YesNo
If Yes, Please privode the marriage and divorce dates*
Family Information
Do you have any children?*

YesNo
Children currently living in the home (click "add row" for each child)
Children no longer living in the home (click "add row" for each)
Are any of your children deceased?*

YesNo
If yes, please list name and date of death:*
All adults (aged 18+) living in the home (click "add row" for each)
Other occupants living in/frequenting the home (click "add row" for each)

Personal History (for all adults and children living in the home)*

	Yes	No
Have any of the adults or children living in the home ever been arrested as a juvenile?
Have any of the adults or children living in the home ever been arrested as an adult?
Have any of the adults or children living in the home ever received treatment for behavioral disorders?
Have any of the adults or children living in the home ever been institutionalized?
Have any of the adults or children living in the home ever been referred to the Protective Services Division?
Have any of the adults or children living in the home ever been previously attempted to become a foster parent/adopt/been licensed through another agency?

If you answered "Yes" to any of the above questions, please explain the circumstances/history in detail including who, what, where, and when.
Please list all current living immediate family members (click add row for to add each person)
References

Please submit 4 separate references per applicant, only one reference may be a relative. Applicant couples must have 8 unique references total.
1. Reference Name

First NameLast Name
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
2. Reference Name

First NameLast Name
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
3. Reference Name

First NameLast Name
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
4. Reference Name

First NameLast Name
Relationship
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Zero Tolerance Policy
Please Check Appropriate Field*

I have NO pending or prior arrests or charges related to child sexual abuse. I have no convictions related to any other form of child abuse and/or neglects. I have no pending or prior arrests and/or substantiated referrals to a child protective services agency.I HAVE been arrested, charged, and/or convicted of child sexual abuse, child abuse and/or neglect, felonies, including violent felonies, and/or have had a substantiated referral to a child protective services agency.
Couples applying to be foster parents must EACH submit a completed application. Please proceed for Applicant 2:*

Proceed now to complete my spouse/partner's information (their signature will be needed at the end).A separate application will be submitted for my spouse/partner.

Acknowledgements
Acknowledgement of Conditional Application:

By signing this portion of the application, the undersigned applicant(s) are acknowledging they have received a copy of and agree to adhere to the following conditions of the licensure approval process:
1. The persons given as references/past employers/adult children will be contacted and interviewed.
2. Background records and fingerprinting will be checked and verified.
3. A completed statement of monthly income/expenditures for the applicants.
4. All history listed, including but not limited to employment, marriages and divorces, will be verified.
5. Full attendance and participation in Childhaven’s Pre-Service training is required prior to the start of a home study.
6. Consent to and participate in the completion of a full home study.
7. An application for foster care does NOT guarantee a license/approval for placement of a child. An approval or denial is based on the suitability of the family for children for whom Childhaven has responsibility.
8. If my/our application is approved, I/we are NOT guaranteed placement in my/our home.
Acknowledgement of Rules/Regulations

By signing this portion of the application, the undersigned applicant(s) are acknowledging that if approved for licensure, they will adhere to all applicable agency and state statutes, rules, and regulations applying to foster homes including, but not limited to:
1. Working with children and families on reunification or alternate case plan.
2. Working with Childhaven to ensure placement stability, such as accepting only children who can remain in the placement until adopted or discharged from care;
3. Ensuring that the safety of children is paramount;
4. Adherence to foster parent responsibilities as set forth in Placement Services, 8.26.2.12 NMAC.
5. Childhaven has the right and the duty to visit the foster children in the foster home at-will.
6. A foster child shall never be surrendered to the care and control of any person, or relative of the child other than a social worker with CYFD or Tribal, Protective Service Division, or Childhaven, without prior written authorization from Protective Service Division.
7. No independent planning, including adoption planning, for foster children shall be made by Foster Parent(s).
8. If a law officer takes protective custody of any foster child (under Section 32A-4-6 of the Children’s Code) foster parents shall surrender custody of the foster child to the law officer and notify Childhaven immediately.
I/wethe undersigned applicant(s), certify that all the information I/we have provided on this application is true and complete to the best of my/our knowledge. I/we understand that omitting requested information or willfully misrepresenting information on my/our application, in my interview(s), or in the progress of my/our evaluation may result in rejection of my/our application or, if I/we are licensed, termination of licensure.

I/we understand that Childhaven, Inc. will contact my/our references for the purpose of obtaining information relating to or about my/our character/employment history. I/we authorize the release of any information from references/employers to Childhaven. I/we release and discharge Childhaven and my /our current/former employers and/or references from any and all claims or liability which may arise from Childhaven inquiring about me/us in connection with my/our application for licensure with Childhaven.

I/we understand that Childhaven will conduct background searches/criminal records checks to include but not limited to the following: State Court, Sex Offender Registries, Child abuse and neglect check, State, Local, & Federal Law Enforcement, Motor Vehicle Reports, and Children, Youth & Family Departments.
Applicant 1 Typed Name

First NameLast Name
Signature*

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Applicant 2 Typed Name*

First NameLast Name
Signature*

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Foster Parent Application

Applicant 1 Information

Employment Information

Education

Medical History

Marriage/Significant Adult Interpersonal Relationships

Family Information

References

Zero Tolerance Policy

Applicant 2 Information

Employment Information

Education

Medical History

Marriage/Significant Adult Interpersonal Relationships

Family Information

References

Acknowledgements