/ Floor Plan
Child Foster Home
Seniors and People with Disabilities
Children with Developmental Disabilities

Please draw a floor plan of your home on a separate sheet of paper using the following symbols, where appropriate. An example of a floor plan using these symbols has been provided on the back of this page. The floor plan of the home must include: the location of rooms, indicating the bedroom for the foster child, caregivers, and other occupants of the home; and the location of windows, exit doors, smoke detectors, fire extinguishers, and wheel chair ramps, if applicable. Please draw a diagram of the house and property showing safety devices for fireplaces, woodstoves, water features (fountains, ponds, pools, hot tubs), and outside structures and fencing. Please attach this sheet to the back of your floor plan.

Window / Stove / Fire Extinguisher / Stairways
Bed / Fireplace / Smoke Detector / Wood Stove
Ramp / Furnace / Fire Exits
/ / | E |

Please number bedrooms to correspond with those on the application.

Foster Provider/Applicant

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Date

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Address

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City

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State

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Zip Code

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Second Floor Out Side Stairs E= Exits, SD=Smoke Detector, FX=Fire Ext.

SPD4510 (3/05)

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