*Name:
*SSN#:
*Home Phone:
*Work Phone:
*Cell Phone:
*Message Number:
*Emergency Contact Number:
*Name of emergency contact:
*Email:
*DOB:
*Are you over 18 years of age: YesNo
*Have you ever applied to be a foster parent? NoYes If yes, when and where?
*Have you ever been licensed or certified as a foster parent by any county or agency? YesNo If yes, when and where?
*Have you ever been denied a foster parent license or certification or had one revoked? YesNo If yes, please explain:
Three people who can speak of your character and abilities relating to foster parenting. Only one reference may be a relative.
Please check level of education that you have completed. Please indicate school you attended.Please indicate degrees you have recieved.
Please list experience, education, and/or training related to parenting, counseling or youth work.
*Has any member residing in your household ever been arrested or convicted of a crime? YesNo If yes, when and for what reason?
*Do you have any physical condition which impairs your ability to provide adequate & appropriate care for foster Children? YesNo If yes, please explain?
*Have you ever been treated for or subject to mental illness or substance abuse? YesNo
*Have you relocated to California, from another state or county within the past two years? YesNo
*Source of Income
*Gross Monthly Income:
*Are you currently employed? YesNo
Please list places you have been employed for the past five years, current employment first.
*Have you ever been employed under another name? NoYes If yes, list the name
*How many bedrooms?
*How many bathrooms?
*What schools are in your district?
*Do you have a swimming pool at your home or apartments? YesNo
I Declare under penalty or perjury that the statements on this form are correct to the best of my knowledge.
Signature:
Date:
