FOSTER CARE PROGRAM – INTAKE INQUIRY FORM - PLC for Children and Families

Name	DOB/AGE	Email

Name	DOB/AGE	Email

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home)
Phone (Work)
Phone (Mobile/Cell)
EMPLOYMENT STATUS

1.Name

Employer	Title	Monthly Income	Hours Weekly

2.Name

Employer	Title	Monthly Income	Hours Weekly

HOUSEHOLD COMPOSITION
(Proof of Marriage/Separation/Divorce/Death Certificate Required)
Marital status
Number of years

Number of Children	Boy	Age/s	Girl	Age/s

Number of adults in home	Male	Female	Relationship

Number of bedrooms	Number of unoccupied beds

Number of pets	Type	Last date of shots	Proof of shot records

Transportation details

Type/Make	Year

ARE YOU ABLE TO TRANSPORT OR ESCORT CHILDREN IN YOUR CARE TO WEEKLY/MONTHLY APPOINTMENTS?
Why Not?
ARE YOU WILLING TO TRANSPORT AND FACILITATE WEEKLY FAMILY/SIBLING VISITS FOR CHILDREN PLACED IN YOUR CARE?
ARE YOU WILLING TO IDENTIFY, ESCORT, ENROLL & PURCHASE ENRICHMENT ACTIVITIES/EQUIPMENT/PROGRAM/UNIFORMS FOR CHILDREN PLACED IN YOUR CARE?
WHAT IS THE HIGHEST LEVEL OF EDUCATION COMPLETED?
DID YOU RECEIVE YOUR HIGH SCHOOL DIPLOMA/GED?
IN WHICH YEAR DID YOU GRADUATE/RECEIVED GED?
DO YOU HAVE PROOF OF GRADUATION/GED?
ARE YOU WILLING TO APPLY, PAY, RETREIVE AND SUBMIT ALL FBI & CHILD PROTECTIVE SERVICE CLEARANCE FOR ALL ADULTS LIVING IN THE HOME OR WHO VISIT THE HOME FREQUENTLY [ie BOYFRIEND, GIRLFRIEND OR GROWN CHILDREN] PRIOR TO COMPLETION OF THIS PROCESS?
WHY NOT?
MARKET INFORMATION
HOW DID YOU HEAR ABOUT OUR PROGRAM
Your friend's full name
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