The Meadows
Foster Family Application
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I. Family
Information |
Print all information. Please
fill out each section in its entirety, accurate information is essential to the
application process.
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APPLICANT NAME (Last, First Middle) |
MAIDEN/PREVIOUS NAME |
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CO-APPLICANT NAME (Last, First
Middle) |
MAIDEN/PREVIOUS NAME |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE |
OTHER PHONE |
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APPLICANT |
CO-APPLICANT |
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Date of
Birth |
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Social
Security Number |
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Race/Gender |
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Religion/Affiliation |
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U.S.
Citizen? |
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Driver
License Number |
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Language
(s) |
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Marital Status
(include date) |
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Previous
Marriage (Date, City, State) |
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Date
Terminated (specify death, divorce, etc.) |
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Military
Service (include branch, dates) |
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Last
Grade Completed |
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Occupation |
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Employer |
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Annual
Income |
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Work
Phone Number |
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Emergency
Name and Phone Number |
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Has either
applicant previously applied to be a foster parent with Free Will Baptist
Family Ministries? _____
If yes,
please list date(s)
___________________________________________________________________________
Children in the Home
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Name |
Date of Birth |
SSN |
Gender |
School Grade/Occupation |
Relationship to Applicants |
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Children Out of the Home
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Name |
Date of Birth |
SSN |
Gender |
School Grade/Occupation |
Relationship to Applicants |
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Others in the Home
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Name |
Date of Birth |
SSN |
Gender |
School Grade/Occupation |
Relationship to Applicants |
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II. Legal |
Please answer the following
questions concerning previous or current legal issues. If a question is answered as “yes” please
provide information regarding the issue as well as formal documentation. No applicant may be approved who has a FELONY
CONVICTION involving child abuse or neglect, spousal abuse, a crime against a
child or children (including child pornography) or a crime involving violence
including rape, sexual assault, or homicide, but not including other physical
assault or battery. No applicant may be
approved who has a FELONY CONVICTION in the past five (5) years involving
physical assault, battery, or a drug/alcohol related offense.
Are you
currently charged with, or have you even been convicted, placed on probation or
received a suspended sentence for:
Applicant Co-Applicant
1. Any
crime involving children?
YES NO
YES NO
2. Any
crime of violence against another person?
YES NO
YES NO
3.
Possession, sale, manufacturing or transportation of drugs?
YES NO
YES NO
4. Any
other crime?
YES NO
YES NO
If yes,
please explain _____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Applicant Co-Applicant
Have you
had previous involvement with Child Protective Services?
YES NO
YES NO
Have you
had previous involvement with Adult Protective Services? YES NO
YES NO
Have you
had previous involvement with Department of Children’s Services? YES NO
YES NO
If yes,
please describe in detail and give time and place.
________________________________________________
_______________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has either
applicant previously applied to be a foster parent with another agency? ______
If yes,
please list date(s), agency, and amount of experience
_____________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________
Do you
currently have a foster child in your home at this time?
YES NO
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III. Former
Addresses |
Please list your
addresses for the past 10 years. Information
MUST include dates lived at former addresses.
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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NAME |
DATES |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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IV. Work Experience |
Please list work experience for each
applicant.
Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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Co-Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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Co-Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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Co-Applicant
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NAME of EMPLOYER |
DATES EMPLOYED |
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ADDRESS |
CITY |
STATE |
ZIP CODE |
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POSITION HELD |
JOB DUTIES |
REASON FOR LEAVING |
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V. Foster Parent Reference
Information |
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Please list the
complete contact information for each reference. All reference boxes must be completed. Only one (1) relative reference per applicant
may be listed.
Applicant Relative
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NAME |
RELATIONSHIP |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE: |
LENGTH OF TIME KNOWN |
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Co-Applicant Relative
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NAME |
RELATIONSHIP |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE: |
LENGTH OF TIME KNOWN |
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Friend
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NAME |
RELATIONSHIP |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE: |
LENGTH OF TIME KNOWN |
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Friend
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NAME |
RELATIONSHIP |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE: |
LENGTH OF TIME KNOWN |
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Friend
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NAME |
RELATIONSHIP |
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ADDRESS |
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CITY |
STATE |
ZIP CODE |
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HOME PHONE: |
LENGTH OF TIME KNOWN |
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VI. Monthly Family Income and
Expenditures |
Please complete this section in its
entirety. Monthly income MUST cover
monthly expenditures. All foster parents
are required to have an income sufficient to meet the financial needs of the
family.
Employment/Monthly Income
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APPLICANT |
CO-APPLICANT |
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Occupation |
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Employer |
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Years in
Current Position |
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Monthly
Income/Pay |
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Additional
Monthly Income |
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Total
Individual Income |
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TOTAL
COMBINED MONTHLY INCOME |
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Please
list source of additional income (if applicable):
____________________________________________________
Financial Resources
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ACCOUNT |
AMOUNT |
ADDITIONAL |
AMOUNT |
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SAVINGS
ACCOUNT |
$ |
OTHER
(specify) |
$ |
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CHECKING
ACCOUNT |
$ |
OTHER
(specify) |
$ |
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OTHER (specify) |
$ |
OTHER
(specify) |
$ |
Monthly Expenditures
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TYPE |
AMOUNT |
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Home |
Rent |
$ |
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Mortgage |
$ |
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Utilities |
Electricity |
$ |
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Water |
$ |
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Gas |
$ |
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Telephone |
$ |
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Etc. |
$ |
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Insurance |
Homeowners/Renters |
$ |
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Medical |
$ |
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Car |
$ |
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Life |
$ |
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Installment
Payments for: |
Credit
Card |
$ |
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Personal
Loan |
$ |
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Other
(specify) |
$ |
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Additional
Expenses |
Food |
$ |
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Clothing |
$ |
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Health
Care (not to include insurance cost) |
$ |
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School
Expenses |
$ |
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Recreation |
$ |
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Church/Charity |
$ |
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Other
(specify) |
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$ |
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TOTAL MONTHLY EXPENDITURES |
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$ |
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VII. HOME/SAFETY INFORMATION |
Please answer the following
questions to the best of your ability.
1. Do you own your own home? YES
NO
2. What type of housing do you reside
in?
Single Family Multi Family Apartment Condo/Townhouse Public
Housing/Section 8 Mobile Home
3. How many rooms
are in the home? ___________
4. How many
bedrooms are in the home? ___________
5. Is your home lead
safe/free? YES
NO Unsure
6. Are there
weapons in the home? (i.e.- guns, hunting knives, display knives, bows/arrows,
etc.) YES NO
Please list location, storage type, and
accessibility.
____________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
7. Do you have a
pool, spa, or hot tub on the property?
YES NO
If yes, are all county/city codes
met? YES NO
Is there a locked fence surrounding
the pool, spa, or hot tub? YES
NO
8. Do you have
pets? YES NO
If yes,
please list them below
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TYPE OF PET |
RECEIVES VETERINARIAN CARE (Y/N) |
SHOTS/INNOCULATIONS UP TO DATE
(Y/N, list dates) |
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VIII. TYPE OF CHILD YOU HOPE TO
FOSTER |
Please
answer the following questions to the best of your ability at this time. Free Will Baptist Family Ministries
understands the gender/age of the child you hope to foster may change during
the preparation process. As a foster
parent you are encouraged to update this information as you continue to
redefine the child you wish to parent.
Gender:
Male Female Either Age Range: _____Youngest ________Oldest _______Any Ages
Sibling Group: YES NO If yes, how many would you consider
fostering at this time? _______
Would you consider fostering a child from
a racial, cultural, ethnic background other than yours? YES NO
Type of
care you wish to provide: Please select
all the may apply to your family.
Foster Adopt Kinship Respite
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IX. Signatures |
By my
signature below, I hereby certify that the information contained in this
application is, to the best of my knowledge, true and accurately represents my
background and experience. I also verify
that there is nothing in my background that would constitute a health and/or
medical risk to children. I understand
that failure to give complete information or falsification or misrepresentation
of information may prohibit my family from working with Free Will Baptist
Family Ministries and if discovered after licensing, will be grounds for
revocation of my license as a foster parent.
Applicant Signature/Date
Co-Applicant Signature/Date
Please return this
application to:
Free Will Baptist Family Ministries Foster Care
Attn: Director of Recruitment and Training