CLARK COUNTY DEPARTMENT OF FAMILY SERVICES
AGENCY FAMILY FOSTER HOME APPLICATION
This application is for a foster home that is supported by a foster care agency. A family foster home accepts children into their own home which must also be their primary residence. The home can be supported by agency staff but the parents are the primary caregivers in the home and their names are on the license. A home study is required for family foster homes. Bed capacity in such a home can be from one (1) to six (6) beds.
Completed Application includes (copies of documents are acceptable):
1. Agency Foster Home Cover Sheet – completed
2. Application for Agency Family Foster Home – completed – PRINT SINGLE-SIDED
a. If applicant has any history of DFS Hotline complaints, provide explanations of each
i. Contact DFS Records Dept at (702) 455-6683 to obtain records if necessary
b. If applicant has any arrest history, provide the following:
i. Written explanation from applicant
ii. Support letter from Agency
iii. Court disposition records
3. Fingerprint receipt
4. NV Driver’s License or NV Identification Card for non driver
5. TB Results
6. Proof of Social Security number (may be card or other legal documents showing SS #)
7. CPR Card– Adult, Child and Infant CPR and First Aid
8. Proof of valid and current automobile insurance
9. Proof of training
10. Five references, no more than 2 related and all must have know applicant for at least 2 years
11. Verification of Income/Savings for most recent 3 months
12. Marriage/Domestic Partnership Certificate
13. Divorce Decree(s) – 1st and last page only
14. Bankruptcy Discharge (if bankruptcy ever filed)
15. Floor plans showing emergency exit routes
16. Copy of entire lease if renting
17. Homeowners/Renter’s Insurance
18. 2 Utility bills dated within the most recent 3 months (preferably electric and gas)
19. Family photo, including pets and any non-primaries
20. Questionnaire #1 and Questionnaire #2 (for Agencies using SAFE) / TIPS-MAPP Profiles and Assignments (for Agencies using TIPS-MAPP)
21. Completed Home Study
22. Pet Shot Records and/or Statement from Veterinarian if pet can’t be immunized
Agency Foster Home Cover Sheet / Agency:HOME TYPE: PICK ONE Family FosterHouse ParentStaffed Home / LICENSE TYPE: PICK ONE InitialMoveNon-renewalRenewalRe-open / Provider #
Applicant #1 Name: / Cell: () - / Work: () -
Applicant #2 Name: / Cell: () - / Work: () -
Address: / City: / State: NV / Zip:
Email: / Home Phone: () -
Applicant #1 / Applicant #2 / Non-Primary #1 / Non-Primary #2
Adam Walsh State(s):
Fingerprint-Date on Receipt / // / // / // / //
Scope (Date Completed) / // / // / // / //
CANS (Date Completed) / // / // / // / //
A. Arrest History (If yes, must provide B, C & D) / Yes No / Yes No / Yes No / Yes No
B. Explanation from Applicant / Yes No / Yes No / Yes No / Yes No
C. Support letter from Agency / Yes No / Yes No / Yes No / Yes No
D. Final Disposition / Yes No / Yes No / Yes No / Yes No
Applicant #1 / Applicant #2 / Non-Primary #1 / Non-Primary #2
NV Driver’s Lic (Exp Date) or NV Identification Card / // / // / // / //
TB Results (Exp Date) / // / // / // / //
Social Security # Verified
CPR (Exp Date) / // / // / // / //
Auto Insurance (Exp Date) / // / // / // / //
Training Hours / 40 20 / 40 20 / 40 20 / 40 20
Release of Information
Arrest Declaration
Total # References: / Rel: Non Rel: / Rel: Non Rel: / Rel: Non Rel: / Rel: Non Rel:
Verification of Income
Marriage Certificate (Date) / // / // / NOTES:
Maiden Name
Divorce Decree (Date) / // / //
Bankruptcy / PICK ONE N/AYES, DISCHARGE DATE: / PICK ONE N/AYES, DISCHARGE DATE:
Floor Plans / Exit Route Marked Sq Ft
Rights to Property / PICK ONE Lease AgreementMortgage StatementOther-Explain:
Homeowners / Renters Insurance / Expiration Date: //
2 Utility Bills w/in last 3 months / Utility 1 Date
Utility 2 Date
Photo of Family
Photo of Non-Primaries
Photo of Pets / Waiver Approval
NAC 424.
NAC 424.
Date Approved or Date Denied
Questionnaire #1 & #2 / Yes N/A / Yes N/A
TIPS-MAPP Documents / Yes N/A / Yes N/A
Completed Home Study / PICK ONE PS-MAPPSAFEOTHER
Total # of Pets:
Pet Name: / Pet Type: / Shots Due:
Pet Name: / Pet Type: / Shots Due:
Pet Name: / Pet Type: / Shots Due:
Clark County Department of Family Services
Agency Family Foster Home Application
Purpose: An Agency Family Foster Home is a foster home that has been fully licensed by Clark County Department of Family Services (DFS) and has been approved to provide higher level of care services above and beyond those of a traditional family foster care home. Children placed in these homes will typically have a psychiatric diagnosis, be on psychotropic medications and have multiple behavioral issues. These homes must meet the following conditions:
· Can be only licensed up to a maximum of six (6) children – Total number is excluding biological and/or adopted children. Best practice is no more than two (2) unrelated higher level of care foster children per licensed home.
· Must meet the 1 adult to 6 children supervision ratio which does include the family’s own minor children as part of the ratio.
· Must meet all minimum licensing standards and must complete additional application requirements which demonstrate the family’s qualifications to provide treatment level services; and
· Must participate, and successfully complete, initial (40 hours) and annual (20 hours) training according to the requirements of foster care regulations outlined in Nevada Administrative Code (NAC) Chapter 424.
An Agency Family Foster Home is generally (but not exclusively) a home that is operated by foster parents who live full time in the home being licensed as their primary residence and who have additional training and expertise in working with children who have specialized needs.
Agency Family Foster Homes contract with and are supported by a parent agency. This agency is generally a corporation (either for profit or non-profit) that has a valid contract with DFS to provide higher level of care services for children in the child welfare system and to recruit and train foster parents. Applicants must apply through a contracted agency and meet their requirements as well as those of DFS. This application packet has all required instructions and materials needed to apply for an Agency Family Foster Home license.
General Instructions
· Applicants seeking to become foster parents as a foster home under an approved agency umbrella must submit this application to the responsible agency, which will then send all application materials to DFS Licensing.· Applicants need to be sure they are fingerprinted for the purpose of being licensed through the agency they are applying with (not for DFS foster care). Applicants who were previously cleared with another agency or DFS still need to be fingerprinted for the agency they are applying with. Fingerprint appointments can be made at 702-455-5146.
· Applicants should seek guidance from their agency representatives for any questions on how to fill out the application.
· Applicants should keep a completed copy of their application materials for future reference. Completed application packets should be forwarded by the agency to:
Clark County Department of Family Services; Agency/Group Home Licensing Unit
121 S Martin Luther King Blvd., Las Vegas, Nevada, 89106
Name of Parent Agency:
Type of Application:
Residence Information:
Residence Address: / City: / State: NV / Zip:Type of Residence: PICK ONE HouseApartmentCondoMobile Home - year built: / Do you own or rent? PICK ONE OwnRentOther (Specify)
Square Footage of Residence: / Length of Time at Residence:
Mailing Address (if different): / City: / State: NV / Zip:
Home Phone #: () -
APPLICANT #1 / APPLICANT #2
Full Name:
Alias, Maiden, or Other Names Used:
Cell Phone #: / () - / () -
Email Address:
Gender: / PICK ONE FemaleMale / PICK ONE FemaleMale
Date of Birth: / // / //
City, State; Country of Birth / , ; / , ;
Social Security Number: / -- / --
PICK ONE Driver's License NumberIdentification Card Number
State Issued By:
Race: / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
Ethnicity: / PICK ONE HISPANIC OR LATINONON-HISPANIC OR LATINO / PICK ONE HISPANIC OR LATINONON-HISPANIC OR LATINO
If Native American/Alaskan Native Tribe, provide Tribal /Member number:
Religion/Faith:
Are you a US Citizen? / PICK ONE Yes No / PICK ONE Yes No
Are you a Legal Resident?
If “yes,” provide ID #: / PICK ONE Yes ID #Not ApplicableNo / PICK ONE Yes ID #Not ApplicableNo
Language(s) Spoken:
Highest Level of Education: / PICK ONE Did not complete high schoolHigh School or GEDTechnical SchoolSome CollegeAssociate's DegreeBachelor's Degree - Please specifyMaster's Degree - Please specifyAdvanced graduate work - Please specifyPh.D. - Please specify / PICK ONE Did not complete high schoolHigh School or GEDTechnical SchoolSome CollegeAssociate's DegreeBachelor's Degree - Please specifyMaster's Degree - Please specifyAdvanced graduate work - Please specifyPh.D. - Please specify
Occupation:
Employer:
Employer Address:
Work Phone: / () - / () -
How long at current job?
Work hours:
Do you have health insurance? / PICK ONE Yes - Agency Name:No / PICK ONE Yes - Agency Name:No
Would your health insurance cover an adopted child? / PICK ONE YesNo / PICK ONE YesNo
List Addresses for Previous 5 Years: (Use additional pages if necessary)
CHECK IF FOR APPLICANT / STREET ADDRESS, CITY, STATE, ZIP CODE / DATE#1 / #2 / FROM / TO
List ALL Household Members: (Use additional pages if necessary)
Name / Date of Birth / Social Security # ** / Gender / Race / Relationship to Applicants (son, stepdaughter, etc.)#1 / #2
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
// / -- / PICK ONE FemaleMale / PICK ONE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther - Please specify
List Extended Family NOT Living in the Home: (Use additional pages if necessary)
Name / Age / Occupation / Address / Phone / Relationship to Applicants(child, parent, sibling)
#1 / #2
() -
() -
() -
() -
() -
() -
() -
() -
List Household’s Average Monthly Income & Attach Documentation of Income:
1st Job Income
2nd Job Income
Social Security/SSI/SSDI
Child or Spousal Support
Unemployment Compensation
Workers’ Disability Compensation
Veterans Benefits
Retirement Benefits
Monies from Boarders or Roommates
Child Care Assistance
Housing Assistance
Rental Income
Other, please specify:
Other, please specify:
TOTAL MONTHLY INCOME / $
List Household’s Assets & Attach Documentation of Income: (Use additional pages if necessary)
Applicant #1 / Applicant #2 / TotalChecking Account(s)
Savings Accounts(s)
Stocks/Bonds
Trust/Annuity
Real Estate
Other:
TOTAL HOUSEHOLD ASSETS
Applicant #1 / Applicant #2
Have you ever applied for bankruptcy? / PICK ONE Yes No / PICK ONE Yes No
Location and chapter of bankruptcy / State: Chapter: / State: Chapter:
Date order was filed/discharged (attach disposition) / // / //
Monthly Household Expenses
SHELTER TOTAL / $ / INSURANCE/HEALTH CARE TOTAL / $
Mortgage/Rental Payment (include HOA) / Life/Auto/Property
Home Maintenance / Medical/Dental (include prescriptions and expenses not covered by insurance)
Taxes/Insurance (if not included) / Other:
Other: / TRANSPORTATION TOTAL / $
FOOD & HOUSEHOLD TOTAL / $ / Gas/Repairs/Maintenance
Groceries/Beverages / Registration
Cleaning Supplies/Paper Products / Bus/Carpool
Food Away from Home/Restaurants / Other:
Tobacco/Alcohol / MONTHLY OBLIGATIONS TOTAL / $
Other: / Alimony/Child Support
UTILITIES TOTAL / $ / Total Auto Loans
Gas/Water / Total Credit Cards
Power / Other:
Cell/Mobile Phone/Internet Services / PERSONAL CARE TOTAL / $
Phone (Landline) / Beauty/Barber Shop
Cable / Other
Garbage/Sewer / OTHER EXPENSES TOTAL / $
Other: / Pets (Boarding/Food/Vet)
RECREATION TOTAL / $ / Clothing/Shoes
Movies/Hobbies / Babysitting/Daycare
Vacations / Other:
Entertainment
Other: / TOTAL MONTHLY EXPENSES / $
TOTAL MONTHLY INCOME / $
TOTAL MONTHLY EXPENSES / $
Applicant #1 / Applicant #2
1. Have you ever applied to provide foster care? / PICK ONE Yes No / PICK ONE Yes No
If yes, Name of agency you applied with: / Date: //
Address of agency: / City: / State/Zip:
Applicant #1 / Applicant #2
2. Have you ever applied for a childcare license? / PICK ONE Yes No / PICK ONE Yes No
If yes, Name of agency you applied with: / Date: //
Address of agency: / City: / State/Zip:
Applicant #1 / Applicant #2
3. Have you ever applied to adopt a child? / PICK ONE Yes No / PICK ONE Yes No
If yes, Name of agency you applied with: / Date: //
Address of agency: / City: / State/Zip:
Applicant #1 / Applicant #2
4. Have you ever applied for a license to provide care for adults or children? / PICK ONE Yes No / PICK ONE Yes No
If yes, Name of agency you applied with: / Date: //