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FOSTER HOME Application
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Steps
1.
General form description goes here
This section is complete
This section is incomplete
2.
Applicant Information
This section is complete
This section is incomplete
3.
Other Persons Living in Home
This section is complete
This section is incomplete
4.
General Questions
This section is complete
This section is incomplete
5.
Foster Care Questions
This section is complete
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6.
Form Authorization and Submission
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General form description goes here
Iredell County Department of Social Services FOSTER HOME Application
Be sure to complete the application in its entirety. If a question does not apply, please include N/A.
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Applicant Information
Gender:
*
Male
Female
Both
Age Range:
*
0-3
4-10
11-14
15-18
Number of children:
*
-- Select One --
No children
1
2
3
4
5 or more
Full Legal Name:
Applicant #1
*
Applicant #2
Previous Names (including married names):
Applicant #1
Applicant #2
Marital Status:
Applicant #1
Applicant #2
If married, date & place:
Applicant #1
Applicant #2
Date of birth:
Applicant #1
Applicant #1
Applicant #2
Applicant #2
Place of birth (city & state):
Applicant #1
Applicant #2
Race:
Applicant #1
Applicant #2
Gender:
Applicant #1
Applicant #2
Occupation:
Applicant #1
Applicant #2
Employer:
Applicant #1
Applicant #2
Annual salary:
Applicant #1
Applicant #2
Work schedule (example 8am-5pm):
Applicant #1
Applicant #2
Highest grade completed:
Applicant #1
Applicant #2
How long have you lived in Iredell County?
Applicant #1
Applicant #2
Home address (street, apartment number, etc.):
*
City:
*
State:
-- Select One --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachussetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code:
*
Email address(es):
*
Telephone numbers:
Home or main contact #
*
Work #
Cellphone #1
Cellphone #2
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Other Persons Living in Home
Other Persons Living in the Home (includes relatives & non-relatives)
Number of Other Persons:
-- Select One --
1
2
3
4
Person #1
Name:
Relationship:
Birthplace:
Date of Birth:
Date of Birth:
Education/Occupation:
Person #2
Name:
Relationship:
Birthplace:
Date of Birth:
Date of Birth:
Education/Occupation:
Person #3
Name:
Relationship:
Birthplace:
Date of birth:
Date of birth:
Education/Occupation:
Person #4
Name:
Relationship:
Birthplace:
Date of birth:
Date of birth:
Education/Occupation:
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General Questions
Are any children placed in your home in the custody of a county DSS agency?
Yes
No
What agency?
Social Worker Name & Contact Information:
Religious Denomination:
Name & Address of Church:
Have you or any member of your household ever been charged or convicted of a crime?
Yes
No
Please describe the event, including location and date of incarceration.
Have you or any member of your household ever had a child protective services investigation or referral?
Yes
No
Please explain.
Has any member of your immediate family ever been involved in counseling or treatment for:
Alcohol/ Drug Problems
Parent-Child Problems
Child-School Problems
PTSD
Marital Problems
Financial Problems
Mental Illness
Please describe.
Are there any health problems in your family?
Yes
No
Please describe these health problems.
Source of Income (Please Check):
Employment
Other (i.e. Food stamps or public assistance)
Retirement
Social Security
Please describe other source of income.
Description of home:
Number of bedrooms:
-- Select One --
1
2
3
4
5 or more
Please list occupants of each bedroom:
Do you have pets?
Yes
No
Please list number and type of pet(s):
Can you speak any other language?
Yes
No
Please list the languages you can speak:
Have you ever been a licensed foster parent or studied as an adoptive parent?
Yes
No
Please note when and where:
Have you ever applied for adoption and foster care through this agency?
Yes
No
Please indicate when and the results of the application.
References (List three references, unrelated to you.):
Please describe your home:
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Foster Care Questions
Foster Care Questions
How will you help support the reunification process between the foster child placed in your home and his/her family?
*
How will you prepare yourself and your family to cope when a child who you have been fostering is returned to their birth family?
*
What comfort level do you have in working directly with the foster child’s birth parents or extended family?
*
Why are you interested in becoming a foster family?
*
How did you hear about us?
*
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Form Authorization and Submission
By checking the following box, I certify that the information provide on this application is correct to the best of my knowledge. I also authorize the Iredell County Department of Social Services to conduct criminal checks on myself and members of my household.
*
Check here
Please enter today's date:
*
Please enter today's date:
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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