2010 Old Greenbrier Rd. Suite G.

Chesapeake, VA 23320

FOSTER HOME APPLICATION

Caregiver #1 / Birth Date
Caregiver #2 / Birth Date
Marital Status
Home Address

Phone numbers: ______

______

Email Address: ______

Directions to Home from Office
Members of Household
Children (name and birth date) / Adults ( name and birth date)
Caregiver #1 Occupation / Hours
Title/Position / Monthly Income
Employer/Address
Caregiver #2 Occupation / Hours
Title/Position / Monthly Income
Employer/Address

Revised 3/2010

FOSTER HOME APPLICATION for ______

Page 1

Describe your home/neighborhood ___________

______

______

Do you rely upon kerosene or portable heaters? YesNo(please circle one)

Are your sanitary and water system part of a municipal system? Yes No(please circle one)

What will your plan be for childcare after a child is placed with you?______

______

Will transporting a child to frequent appointments be a problem for you?______

Have you ever been a foster parent with another agency? ____ Yes ____ No If yes, list agency name, city, state and dates: ______

What are your reasons for wanting to become a foster parent?______

______

______

What experience have you had with children of different age groups and how would you use that experience becoming a foster parent? ______

______

______

Please describe your hobbies, special interests, and community activities. ______

______

______

How do you think having a child in your home will affect your lifestyle? ______

______

______

What do you imagine will be the most positive thing foster parenting will do for the family?______

______

______

Revised 3/2010

FOSTER HOME APPLICATION for ______

What do you think will be the least positive and/or the most difficult part of foster care?______

______

______

How difficult would it be for you to help a child participate in a religion other than your own? ______

______

______

How do you think you would feel about a foster youth’s biological family and helping prepare them to return home?______

______

How do you emphasize the importance of education to the children in your life? ______

______

What types of discipline do you feel may be best for a foster placement? ______

______

Our training requirements require continued training throughout the year. Are you willing to make this commitment?

____________

Are you (or partner) currently under the care of a physician (including psychiatrist, chiropractor, etc.)? ______

Please provide the name, complete address, phone number and email address of four (4) people, who are not related to you, whom the agency may contact for a personal reference.

Name/Address/Phone Number/Email
Name/Address/Phone Number/Email
Name/Address/Phone Number/Email
Name/Address/Phone Number/Email

Please provide the name, complete address, phone number, email address of your employer, whom we may contact for an employment reference.

Name/Address/Phone Number/Email
Name/Address/Phone Number/Email
Caregiver #1 Signature
Caregiver #2 Signature
DATE

Revised CW 02.01.2016 FP File – To be filed under Pre-Approval Section