Foster Parent Application

    *Name:

    *SSN#:

    *Address:

    *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:

    References


    Three people who can speak of your character and abilities relating to foster parenting. Only one reference may be a relative.

    Name
    Address
    Phone
    Relationship

    Educational Training


    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.

    Personal History

    *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

    Financial Information

    *Source of Income

    *Gross Monthly Income:

    Employment

    *Are you currently employed?
    YesNo

    Please list places you have been employed for the past five years, current employment first.

    Place of Employment
    Phone#
    Dates
    Position

    *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: