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:
 Yes No

*Have you ever applied to be a foster parent?
 No Yes
If yes, when and where?

*Have you ever been licensed or certified as a foster parent by any county or agency?
 Yes No
If yes, when and where?

*Have you ever been denied a foster parent license or certification or had one revoked?
 Yes No
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?
 Yes No
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?
 Yes No
If yes, please explain?

*Have you ever been treated for or subject to mental illness or substance abuse?
 Yes No

*Have you relocated to California, from another state or county within the past two years?
 Yes No

Financial Information

*Source of Income

*Gross Monthly Income:

Employment

*Are you currently employed?
 Yes No

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?
 No Yes
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?
 Yes No

 I Declare under penalty or perjury that the statements on this form are correct to the best of my knowledge.

Signature:

Date: