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					FOSTER PARENT APPLICATION
Instructions: Please complete the Application to the best of your ability. If you have any questions, don’t hesitate to call us, and we will assist you in this process. For questions that do not apply, please mark N/A. I am interested in: Applicant’s Full Name: Applicant’s Full Name: Street Address: City: Home Phone: Cell (Her): Work (Her): Directions to your home: Zip: Time at Residence: Cell (Him): Work (Him): e-mail: Foster Care Foster to Adoption Adoption Respite Care

Number of Bedrooms:

Number of Bathrooms: If yes, please explain.

Have you experienced any major transitions in the last year?

Foster Parenting History How did you hear about All Church Home For Children?

Revised 5/7/08

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Why have you chosen to apply with All Church Home For Children instead of another agency?

What is your reason for wanting to become a foster parent?

What is your experience in working with children?

Have you or your spouse ever applied to another child placing agency to provide foster care? Yes No If “Yes,” please list all agencies to which you have applied starting with the most recent. Agency #1 Date of Application: Name & Address of Agency:

What disposition was made of your application?

Agency #2 Date of Application: Name & Address of Agency:

What disposition was made of your application?

Have you or your spouse ever been a foster parent?

Yes

No

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Have you or your spouse ever been employed as any type of child care provider?

Yes

No

If “Yes,” please list the name(s) of the agencies to which you have been affiliated with starting with the most recent. Agency #1 Date of Application: Name & Address of Agency:

Reason for leaving?

Agency #2 Date of Application: Name & Address of Agency:

Reason for leaving?

Have you ever been denied a foster care license or renewal? Y If yes, please list agency name, address and telephone and explain (including dates of events):

N

Is your home currently licensed, regulated, approved or operated by another agency? If yes, please list agency name, address and telephone:

Y

N

What are the characteristics of the children you are able to care for?

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Number: Age range:

Sex: Male

Female

Races

Are you willing to take a sibling group?

What challenges are you open to learn about and to provide care for? Developmental delays Emotional Needs Mental Retardation Behavioral Problems Are you able to transport the child to appointments and other activities? Military Service Parent 1 Branch Dates Type of Discharge Employment Parent 1 Current Employer Employment Dates Position Direct Supervisor Past Employer Employment Dates Position Reason For Leaving Past Employer Employment Dates Position Reason For Leaving Past Employer Employment Dates
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Minor Health Problems Hearing Impaired Visually impaired

Drug Exposed Sexually Abused Mobility Impaired

Parent 2

Parent 2 From: To:

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

From:
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To:

From:

To:

Position Reason For Leaving May we contact your present & former employers? Y N Y N

Do you have any volunteer experience? If so, please describe?

Organizations or groups you belong to:

Interest and activities you have:

Citizenship Are you a United States citizen? Y Y N N If no, where?

Have you lived in Texas three or more years?

List all cities in Texas in which you have lived at any time throughout your life (include dates):

Parent 1 Place of Birth Date of Birth Social Security Number Driver’s License Number Highest Education Achieved (include name of school, year graduated, and degree) Describe any other training or education achieved

Parent 2

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Occupation Employer Yearly Gross Salary (continued) Work Hours Length of time with current employer Distance from home Can you receive calls at work? Previous states of residency Other names used (include nicknames and maiden names) Race What are your long term employment goals? Parent 1 Parent 2

In case of emergency, please notify (name, relation, address and phone number):

FINANCIAL STATEMENT Monthly Income: Source Gross Net Total His Hers

Do you own or rent your home? Do you have health insurance?

own yes

rent no

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Children (Please list ALL – living, deceased, at home or away from home) Child 1 Name: Birth Date: In Home: Y N Age: Student: If no, where? Biological Biological Step Step Adopted Adopted Gender: M F

Relationship to Parent 1: Relationship to Parent 2:

Child 2

Name: Birth Date: In Home: Y N Age: Student: If no, where? Biological Biological Step Step

Gender:

M

F

Relationship to Parent 1: Relationship to Parent 2: Child 3 Name: Birth Date: In Home: Y N Age:

Adopted Adopted Gender: M F

Student: If no, where? Biological Biological Step Step Adopted Adopted Gender: M F

Relationship to Parent 1: Relationship to Parent 2: Child 4 Name: Birth Date: In Home: Y N Age:

Student: If no, where? Biological Biological Step Step Adopted Adopted

Relationship to Parent 1: Relationship to Parent 2:

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Child 5

Name: Birth Date: In Home: Y N Age: Student: If no, where? Biological Biological Step Step

Gender:

M

F

Relationship to Parent 1: Relationship to Parent 2: Current Marriage Date of Marriage: Previous Marriages

Adopted Adopted

Place (County & State):

Parent 1 Number of Previous Marriages Name of Previous Spouse Date of Marriage Place of Marriage (County & State) Reason for Divorce/Death Date of Divorce/Death

Parent 2

Name of Previous Spouse Date of Marriage Place of Marriage (County & State) Reason for Divorce/Death Date of Divorce/Death

Family Activities and Interests Describe the nature of your typical family activities – what types of activities your family is involved in, how often activities are performed, favorite vacation places, etc.
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Pets Please list all pets you currently own:

Others Residing in the Home Name 1. 2. Comments: Will any of these people have any child care responsibilities for the foster children? Explain: Y N Age Relationship

Please list those persons other than your own children who have lived with you anytime in the past 15 years. Give name, date of birth, and relationship to you.

Adult Children Please provide name, mailing address, and phone number of all adult children: 1. Name: Address: 2. Name: Address:
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Phone Number:

Phone Number:

3. Name: Address: Religion Parent 1 Denomination Church Name/Location Frequency of Attendance Special Involvement Transportation Do you own a car? Y N

Phone Number:

Parent 2

Please list all vehicles that might be involved in transportation of foster children. Year Make Model Condition

His: Driver License Number Her: Driver License Number

State State Y N

Do you have liability and personal injury protection insurance on your vehicle(s)? Name of your auto insurance company: Auto Insurance Policy Number:

(Please provide current photocopies of each applicant’s driver’s license and proof of auto insurance.) Medical Information
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Date of last medical physical exam and results: His: Hers: Major illnesses you have had in the last year: His: Hers: A. Does any member of your household have a physical handicap? Does any member of your household have a medical condition? If Yes, Please Explain: Y Y N N

B.

Has any member of your household ever sought counseling or treatment for any mental, emotional or nervous condition?

Y

N

If yes, please explain (include prescribed psychotropic medications, mental health diagnoses, etc):

Please provide: Family member’s name: Counselor’s name: Address: Telephone: Psychiatrist’s Name:

Please use the back of this sheet to provide additional information and family members.

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C.

Has any member of your household ever received treatment for or had a problem with the use of alcohol or drugs If yes, please explain:

Y

N

D.

Do you smoke tobacco products (i.e. cigarettes, pipes, and cigars)?

Y

N

All Church Home encourages parents that smoke to not do so in the presence of the children due to the dangers of second hand smoke. Minimum Standards requires that foster parents do not smoke in their homes or vehicles. If you do smoke, explain what measures you will take to keep the smoke away from children and provide a smoke-free living environment (i.e. only smoke outdoors, no smoking in vehicles, etc.).

Legal Information A. Has anyone in your household ever been charged, arrested, and/or convicted of a misdemeanor or felony, including domestic violence disturbances? Explain:

Y

N

B.

Have any individuals who visit your home ever been charged, arrested, and/or convicted of a misdemeanor or felony, including any domestic violence disturbances? Explain:

Y

N

C.

Is anyone in your household presently involved in a civil suit or now paying judgement rendered in civil action? Explain:

Y

N

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D.

Has any member of your household ever had any allegations, charges, or convictions against them for child abuse or neglect? Explain:

Y

N

E.

Have any of your children been temporarily or permanently removed from your home by the courts or Child Protective Services? Explain:

Y

N

F.

Have any individuals who visit your home ever had any allegations, charges, or convictions against them for child abuse or neglect? Explain:

Y

N

G.

Has your family had any police visits, including domestic violence disturbances, to your home that did not result in an arrest or citation? Explain:

Y

N

H.

Has anyone in your home had any police involvement, including domestic violence disturbances that did not result in an arrest or citation? Explain:

Y

N

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I.

Has anyone in your home been involved in a civil lawsuit? Y Explain: N

J.

Has anyone in your family filed for bankruptcy? Y Explain: N

Home and Community A. How far is the nearest hospital from your home? B. What type of water service do you use? City County Well

Describe your neighborhood community: (include comments regarding ethnic and socioeconomic composition)

Will each foster child have a separate bedroom? Will the foster child share a bedroom with anyone? If yes, who will be sharing the room? Do you have trampoline? Do you have a swimming pool? If so, please explain how you will provide for a child's safety:

Y Y

N N

Y Y

N N

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Do you own a gun? (any type)

Y

N

If yes, please list ALL firearms, how they are stored, how ammunition is stored, and explain how you will provide for a child's safety:

Do you have any explosive materials and/or projectiles such as darts, arrows, and B-B's?

Y

N

If yes, please list where these materials and objects are stored and your safety plan for keeping them out of reach of the children.

Where do you store your inflammable and poisonous substances? How are they kept out of reach of children?

References Please list five (5) persons or couples not related whom we may contact for a reference who have known you for a minimum of three (3) years and who are well acquainted with your family. It is important that all information is complete. (NOTE: If you are a married couple applying, only one of you must complete this section of the Application. However, please ensure that you include references for each spouse. For example, do not list 4 references that are close friends only with the wife, but do not know the husband very well). 1.) Name: Address: City, State, Zip Code: Telephone Number: E-Mail: Relationship:
Revised 5/7/08 Page 15 of 17

2.)

Name: Address: City, State, Zip Code: Telephone Number: E-Mail: Relationship:

3.)

Name: Address: City, State, Zip Code: Telephone Number: E-Mail: Relationship:

4.)

Name: Address: City, State, Zip Code: Telephone Number: E-Mail: Relationship:

5.)

Name: Address: City, State, Zip Code: Telephone Number: E-Mail: Relationship:

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Is there any other information you feel All Church Home should consider in reviewing your Application? If so, please comment below.

I hereby declare that the information provided by me in this Application for Foster Care is true, accurate and complete to the best of my knowledge. I give my permission for any of this information to be verified and I understand that if any of this information is found to be inaccurate or false, this may be used to terminate any further consideration of my Application. I give my consent for any agency, employers, companies, friends or family to be contacted.

Parent 1 Signature

Date

Parent 2 Signature Contractual Relationship

Date

I acknowledge my understanding that All Church Home reserves the right to decline any Prospective Foster Parent during any part of the licensing process. I also understand that at any time during the licensing process I may decide not to continue the process.

Parent 1 Signature

Date

Parent 2 Signature

Date

Thank you for your interest in All Church Home for Children. Please return the completed Application to: All Church Home for Children Attn: Foster Care Recruiter 1424 Summit Avenue Fort Worth, Texas 76102

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