FOSTER PARENT APPLICATION

Parent 1 Full Name ______

Parent 2 Full Name ______

Address (must be street address) ______

City ______State ______Zip ______County ______

Home Phone ( ____) ______How Long At Current Address ______

Relationship of Parent 1 and Parent 2 (check one):

Husband/Wife ______Parent/Adult Child ______Friends/Roommates ______

Parent 1

/ Parent 2
Date of Birth
Highest Education Achieved
Last Year of School
Occupation
Work Hours
Length of Time with
Current Employer
Time in Current Position
Distance from Home
Work Phone
Can You Receive Calls at Work
Previous States of Residency
Any Previous Names

Military Service

Parent 1 ______Parent 1 ______

Branch ______Branch ______

Dates ______Dates ______

Type of Discharge ______Type of Discharge ______

Parent 1

/ Parent 2
Current Employer
Employment Dates / From: To: / From: To:
Position
Direct Supervisor (with phone #)

Past Employer

Employment Dates / From: To: / From: To:
Position
Direct Supervisor (with phone #)
CHILDREN (Please list ALL – living, deceased, at home or away from home children)
Child 1

Name (full) ______Gender M ___ F ___

Birth Date ______Grade ______In Home Y N If No, where ______

Relationship to Parent 1:Biological____Step____Adopted____

Relationship to Parent 2:Biological____Step____Adopted____

Child 2

Name (full) ______Gender M ___ F ___

Birth Date ______Grade ______In Home Y N If No, where ______

Relationship to Parent 1:Biological____Step____Adopted____

Relationship to Parent 2:Biological____Step____Adopted____

Child 3

Name (full) ______Gender M ___ F ___

Birth Date ______Grade ______In Home Y N If No, where ______

Relationship to Parent 1:Biological____Step____Adopted____

Relationship to Parent 2:Biological____Step____Adopted____

Child 4

Name (full) ______Gender M ___ F ___

Birth Date ______Grade ______In Home Y N If No, where ______

Relationship to Parent 1:Biological____Step____Adopted____

Relationship to Parent 2:Biological____Step____Adopted____

Child 5

Name (full) ______Gender M ___ F ___

Birth Date ______Grade ______In Home Y N If No, where ______

Relationship to Parent 1:Biological____Step____Adopted____

Relationship to Parent 2:Biological____Step____Adopted____

ADULT CHILDREN

Please provide adult children’s name, address and phone number.

CURRENT MARRIAGE

Date of Marriage ______Place (County & State) ______

PREVIOUS MARRIAGES
Parent 1 / Parent 2
Number of Previous Marriages
Name of Previous Spouse
Date of Marriage
Place of Marriage (county & state)
Reason for Divorce/Death
Date of Divorce/Death
Name of Previous Spouse
Date of Marriage
Place of Marriage (county & state)
Reason for Divorce/Death
Date of Divorce/Death
OTHERS RESIDING IN YOUR HOME

Name, age, and relationship

  1. ______
  1. ______

Comments ______

Will any of these people have any child care responsibilities for the foster children? Y ____ N_____

Explain ______

FAMILY ACTIVITIES & INTEREST

Please explain ______

______

______

FAMILY PETS

______

RELIGION

Parent 1Parent 2

Denomination ______

Church Name & City ______

Attendance Frequency ______

Special Involvement______

Pastor’s Name & Phone ______

MEDICAL INFORMATION

1.Does your personal physician accept Medicaid or the KY Medical Card? ______

2.Does any member of your household have a physical handicap? ______

3.Does any member of your household have a medical condition? ______

If yes to 2 or 3, explain ______

______.

4.Has any member of your household ever sough counseling or treatment for any mental, emotional or nervous condition? ______. If yes, explain ______

______

If yes, please provide:

Family member’s name ______

Counselor’s name ______Psychiatrist’s name ______

Address ______Address ______

Phone ______Phone ______

5.Has any member of your household ever received treatment for, or had a problem with the use of alcohol or drugs? ______. If yes, explain ______

______

LEGAL INFORMATION

1.Has any member of your household ever been charged, fined or convicted for violation of any law? ______If yes, explain (including dates) ______

______

2.Is anyone in your household presently involved in a civil suit or now paying judgment rendered in civil action? ______If yes, explain ______

______

3.Has any member of your household ever had any allegations or charges of abuse or neglect brought against them? ______If yes, explain (including dates)______

______

4.Have any of your children been temporarily or permanently removed from your home by the courts of Child Protective Services? ______If yes, explain (including dates) ______

______

PREVIOUS FOSTERING EXPERIENCE

A.Have you ever applied to become foster parent(s)? ______

If yes, agency name & address ______

What was outcome of application ______

B.If you have provided foster care for another agency, please explain why you no longer foster for that agency. ______

______

C.The decision to close your home was made by:You_____The Agency_____

D.Were you in agreement with the closure? ______Explain ______

______

FINANCIAL STATEMENT

Providing foster care for children creates some new financial responsibilities. Foster parents are provided a monthly amount to reimburse them for the costs of caring for a child in their home. Will caring for a child in your home create undue financial burden for your family? Y ______N ______.

HOME & COMMUNITY

1.Elementary School in your district ______

2.Middle School in your district______

3.High School in your district ______

4.How far is the nearest hospital from your home? ______

5.What type of water service do you use? City_____ County_____ Well_____

All of the information provided in this application is true and complete to the best of my/our knowledge. I / We understand that falsification of data so given or derogatory information discovered as a result of this investigation will likely prevent my/our being certified as foster parent(s).

Parent 1 SignatureDate

Parent 2 SignatureDate