/ Tennessee Department of Children’s Services
Contingency Plan-Foster Home

In the unlikely event that I/we both are incapacitated, the following individuals have agreed to step in and provide care for the child(ren) placed in my/our home until such a time as the Department of Children’s Services is able to make other arrangements or I am/we are able to resume parenting responsibilities.

Foster Home Name / Date Completed:

Choice #1

Name/Relationship:
Address:
Phone Numbers:

Choice #2

Name/Relationship:
Address:
Phone Numbers:

These individuals have been provided with contact information for the Department of Children’s Services and have agreed to contact the child(ren)’s Family Services Worker or Emergency On-Call immediately in the event of an emergency or my/our death(s), as soon as possible to make further arrangements.

Foster Parent Date
Foster Parent Date

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.

Distribution: F. H. case file, F.H parents RDA 2982

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