Foster Parent Application




*Home Phone:

*Work Phone:

*Cell Phone:

*Message Number:

*Emergency Contact Number:

*Name of emergency contact:



*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:


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


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:


*Are you currently employed?
 Yes No

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

Place of Employment

*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.