FOSTER CARE PROGRAM – INTAKE INQUIRY FORM POTENTIAL FOSTER PARENT DEMOGRAPHICSNameDOB/AGEEmail NameDOB/AGEEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Home)Phone (Work)Phone (Mobile/Cell)EMPLOYMENT STATUS1.NameEmployerTitleMonthly IncomeHours Weekly 2.NameEmployerTitleMonthly IncomeHours Weekly HOUSEHOLD COMPOSITION(Proof of Marriage/Separation/Divorce/Death Certificate Required)Marital statusSingleMarriedSeparatedDivorcedCo-habitatingNumber of years Number of ChildrenBoyAge/sGirlAge/s Number of adults in homeMaleFemaleRelationship Number of bedroomsNumber of unoccupied beds Number of petsTypeLast date of shotsProof of shot records YesNo LICENSING MANDATESARE THERE ANY OUTSTANDING HOME/RENTAL REPAIRS UNDERWAY WE NEED TO KNOW ABOUT?YesNoRepairs underwayDO YOU HAVE ACCESS TO YOUR OWN AUTOMBILE/TRANSPORTATION?YesNoTransportation detailsType/MakeYear ARE YOU ABLE TO TRANSPORT OR ESCORT CHILDREN IN YOUR CARE TO WEEKLY/MONTHLY APPOINTMENTS?YesNoWhy Not?ARE YOU WILLING TO TRANSPORT AND FACILITATE WEEKLY FAMILY/SIBLING VISITS FOR CHILDREN PLACED IN YOUR CARE?YesNoARE YOU WILLING TO IDENTIFY, ESCORT, ENROLL & PURCHASE ENRICHMENT ACTIVITIES/EQUIPMENT/PROGRAM/UNIFORMS FOR CHILDREN PLACED IN YOUR CARE?First ChoiceSecond ChoiceThird ChoiceWHAT IS THE HIGHEST LEVEL OF EDUCATION COMPLETED? DID YOU RECEIVE YOUR HIGH SCHOOL DIPLOMA/GED?YesNoIN WHICH YEAR DID YOU GRADUATE/RECEIVED GED? DO YOU HAVE PROOF OF GRADUATION/GED?YesNoARE 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?YesNoWHY NOT?MARKET INFORMATIONHOW DID YOU HEAR ABOUT OUR PROGRAMNewspaperRadionFriendYour friend's full name CommentsCAPTCHA Δ