FOSTER PARENT APPLICATION

Please complete all information requested. If any item does not apply to you, please write “N/A” or “None” so there will not be any delay in the processing of your application.

Save & Return

Save your progress and complete this form later. (optional)

Please fill all areas of the form that apply. Fields with a * are required fields. Field headers with ? by them have helpful information. Make sure you read and select the proper answer on the first secion of questions, they will activate fields that are currently hidden based on the default selections.

Are you a: Please check one: *

Are you Currently Married? *

Other than current marriage have you been married before? * 

Application is for: (Single or Non Marrried Couples) * 

Do you own a pet or pets? *



Identifying Information


Applicant's Name
Co-Applicant

Current Address

We currently need to have at least 10 years of Address history, When you enter the number of years you have lived at the current location and it is less than 10 years more, fields will show up, so you can enter other information on Address History.


 
 If less than 10 years, list previous address(es) where you lived in the last 10 years
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Contact Information

Applicant's *
 CellWorkFax
Phone Numbers

Co-Applicant's *
 HomeCellWorkFax
Phone Numbers

Personal Information

Applicant's
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Co-Applicant's
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Applicant's Marital History

Current Status if Married was not checked above: *

                        Current Marital Informaiton
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Applicant's Previous Marriages
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How it ended
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How it ended
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How it ended

Co-Applicants Marital History

Current Status if Married was not checked above:

Co-Applicant's Previous Marriages
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How it ended
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How it ended
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How it ended

Academic History

Applicant's History ( Please indicate the highest education status attained) *
Co-Applicant's History ( Please indicate the highest education status attained) *

Household Information

Information about other peopel living in your home including foster children, if any
 Full Name(Last, First, Middle)How RelatedDOBSexSchool or OccupationSocial Security NumberIf Foster, DFPS Casework's Name & Number
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Give the names of all of your children or the co-applicant's children who live outside your household. Include gronw children. According to the Minimum Standards For Child Placing Agencies, all of the children living outside your household, who are 12 years and older, will have to be contacted by AWFC to complete a child reference.
 Full Name (Last, First, Middle)SexAgeComplete AddressPhone NumberWhose Child? (Applicant or Co-Applicant
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Previous Child Care Experience

Applicant's 
 Type of ActivityAges of YouthDates
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Co-Applicant's 
 Type of ActivityAges of YouthDates
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Foster Parent History


Have you or the co-applicant ever:

Applied to another agency to adopt a child or become a Foster Parent? *
if Yes, was your application accepted? *
Been licensed with another agency? *
Adopted through another Agency? *
Been a house parent or worked in a treatment center either as a volunteer or a paid employee? *
If yes, as a: *
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Please Note:  If you answered YES to any of the above, you must complete the remainder of this section. We are providing space for up to three agencies. If more than three, please create a document with other agencies information and upload at the end of this application.

Agency Information

If Licensed: Dates
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Agency Information

If Licensed: Dates
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Agency Information

If Licensed: Dates
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Personal References

Please list the names and addresses of four persons or couples not related to you who have known you well enough for at least two years to inform us accurately regarding your moral character and life style. Local references are preferred, but if none are available please give the address and home phone number for out of town references. For local references, please try and provide the home and business phone numbers. Please try to vary the nature of your references, including htose from spirtual, business, or employment relationships, as well as social relationships.
Non Related References
 NameStreetCityStateZipHome, Work, Cell Phone Number
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Community References

Please list the anmes and address of two persons or couples not related to you and who line in your community (ex: clergy, neighbor, school employees or other community members) who have know you well enough for at least two years to inform us accurately regarding your moral character and life style.
Non Related Community References
 NameStreetCityStateZipHome, Work, Cell Phone Number
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Relative References

Please list the names and address of one person related to you and not living in your home that you believe will inform us accurately regarding your moral character and life style. Local references are preferred but if none are available, relatives that reside out of  town are acceptable if they know you well enough to complete hte reference questionnaire.
Relative References
 NameStreetCityStateZipHome, Work, Cell Phone Number
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Employment History

Show all employment for the last five years.

If employed less than five years, Please list previous employment below:

Co-Applicant's Employment History:

If employed less than five years, Please list previous employment below:

Income & Expenses

Please provide the following information about your financial status

Monthly Income

Applicant's Income Source *

Co-Applicant's Income Source *

All Other Household Income Sources:
A Copy of your most recent income tax statement or paycheck stub
is requried for your file to meet state minimun standards


Net Total:
$0.00

Assets

Specify Sources (Stocks,Bonds,Savings,Investments,Interest Bearing Accounts,etc.)
Do you own your home or do you rent? *

Household Expenses

Enter you household's average monthly expense for the following items. DO NOT INCLUDE EXPENSES THAT ARE DEDUCTED FROM PAYCHECKS











0/80 characters
Total Monthly Expenses
$0.00

Personal Background Information

Please check appropriate box for each question
As an adult or when you were a child, have you ever been involved in an act of assault, child battering, child abuse, child molestation, or child neglect either as an aggressor or as a victim?
Applicant *

Co-Applicant *
Have you been convicted or are you currently charged with a felony or misdemeanor classified as an offense against the person, family, pbulic indecency, or any violation of the Controlled Substance Act?
Applicant *

Co-Applicant *
Have you ever been arrested or charged with a felony?
Applicant *

C0-Applicant *
Do you object to a criminal records check?
Applicant *

Co-Applicant *
Have any of  your children ever been placed in foster care, a treatment facility for emotional or mental disturbance, been arrested and/or charged with an offence, and/or been committed to a state correctional facility?
Applicant *

Co-Applicant *
Do you expect any change in marital status, employment, family size or place of residence within the next year?
Applicant *

Co-Applicant *
If either Applicant or Co-Applicant answered Yes to above question please explain.

Medical History

Have you had a history of or treatment for any of the following?
Applicant * 
 YesNo
Cancer
Severe Arthritis
Chronic Kidney Condition
Colitis
Ulcers
Hay Fever
Allergies
Asthma
Seizures
Neck Injury
Back Injury
Heart Condition
Heart Attack
Stroke
Hemophilia
Diabetes
Chronic Headache
Chronic Fatigue
Insomnia
Hepatitis
Lupus
Other


Co-Applicant * 
 YesNo
Cancer
Severe Arthritis
Chronic Kidney Condition
Colitis
Ulcers
Hay Fever
Allergies
Asthma
Seizures
Neck Injury
Back Injury
Heart Condition
Heart Attack
Stroke
Hemophilia
Diabetes
Chronic Headache
Chronic Fatigue
Insomnia
Hepatitis
Lupus
Other

Explain Your Answers:

Applicant

Applicant *
 YesNo
Are you now receiving or have you ever received treatment for chemical dependency?
Are you now or have you ever received treatment for alcohol dependency,alcoholism?
Have you had history of or received treatment for depression?
Have you ever intentionally hurt yourself or attempted to commit suicide?
Have you had a history of or received treatment for an emotional or mental illness or family problems?
Are you now receiving or have you ever received psychiatric treatment?
If Yes have you ever had a psychological examination or battery of psychological tests?
 When?
If yes
If yes
If yes
If yes
If yes
If yes
If yes
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Applicant *
 YesNo
Are you now or have you ever taken medication for mental or emotional problems?
 When
if Yes
Applicant *
 YesNo
Do you have a physical Disability?
Do you have any significant, acute, or chronic medical conditions that could effect your ability to foster parent children?
Are you physically able to have children?
 What / Why
If yes, what?
If yes, what?
If yes, Why?

Co-Applicant

Co-Applicant *
 YesNo
Are you now receiving or have you ever received treatment for chemical dependency?
Are you now or have you ever received treatment for alcohol dependency,alcoholism?
Have you had history of or received treatment for depression?
Have you ever intentionally hurt yourself or attempted to commit suicide?
Have you had a history of or received treatment for an emotional or mental illness or family problems?
Are you now receiving or have you ever received psychiatric treatment?
If Yes have you ever had a psychological examination or battery of psychological tests?
 When?
If yes
If yes
If yes
If yes
If yes
If yes
If yes
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Co-Applicant *
 YesNo
Are you now or have you ever taken medication for mental or emotional problems?
 When
if Yes
Co-Applicant *
 YesNo
Do you have a physical Disability?
Do you have any significant, acute, or chronic medical conditions that could effect your ability to foster parent children?
Are you physically able to have children?
 What / Why
If yes, what?
If yes, what?
If yes, Why?

Hospitalizations

List all admissions to a Hospital
 Date (mm/dd/yyyy)Reasons
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Medications

List all prescription medications being taken on a regular basis
 AppCo-App
Prescribed to:
Prescribed to:
Prescribed to:
Prescribed to:
Prescribed to:
Prescribed to:
Prescribed to:
Prescribed to:
 MedicationReasons for Medication
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Date of last visit to doctor and reason

Applicant:
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Co-Applicant:
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List all illnesses you have had in the past year:

Are your children current on their immunizations?

Pets

You have indicated that you have pets, please fill in the information below.
Pet Information
 TypeBreedAgeVaccinations Up To Date (Yes) (No)Rabies Vaccination (Yes) (No)
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