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Note: This is offered here as a guideline only. It is not an actual application.

The Foster Care Agency is required to assess a potential foster home according to state regulations (3700.64). Any information you can provide us in these area will help us in making our assessment.

The FFCA (Foster Family Care Agency) regulations are as follows:

(A) The FFCA shall consider the following when assessing the ability of applicants for approval as foster parents:

  • The ability to provide care, nurturing and supervision to children.
  • A demonstrated stable mental and emotional adjustment. If there is a question reguarding the mental or emotional stability of a family member which might have a negative effect of a foster child, the FFCA shall require a psychological evaluation of that person before approving the foster home.
  • Supportive community ties with family, friends and neighbors.

(B) In making a determination in relation to subsection (a) the FFCA shall consider:

  • Existing family relationships, attitudes and expections regarding the applicant's own children and parent/child relationships, especially as they might affect a foster child.
  • Ability of applicant to accept a foster child's relationship with his own parents.
  • The applicant's ability to care for children with special needs, such as physical handicaps and emotional disturbances.
  • Number and characteristics of foster children best suited to the foster family.
  • Ability of the applicant to work in partnership with an FFCA.

Agency staff will utilize at a minimum the application, references, criminal background checks, childline background checks, physical exams, foster home inspection report, and interview to make our determination. Our agency's foster homes must be available to children of any race or color. If you have any problems accepting a child of another color into your home, please do not apply to this agency as foster parents.

NOTE: This is offered here as a guideline only. It is not an actual application, but will give you an idea of the questions asked during your initial application process. If you are interested in pursuing fostering and would like someone in your state to contact you, please fill out our contact form.

Wife's Full Name: _____________________________________
SSN: ____________________
Driver License #: ________________
State: ___________

Husband's Full Name: __________________________________
SSN: ____________________
Driver License #: ________________
State: ___________

Telephone Number: (home) ____________________ (work)_____________________

Home Address:
___________________________________________________
___________________________________________________

How long did family reside here?________________
Write detailed directions to your home:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

List all persons living in your home, along with age, relationship to parents, and occupation: (Name, Age, Relationship, and Occupation):
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

List the reasons why you want to be foster parents:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________ ___________________________________________________

Describe how you feel foster parenting will affect yourselves and your own children. Include what you think will be the positive and negative aspects of foster parenting. Include your biological children's attitudes toward accepting a client into your home.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Describe the attitudes of any significant extended family members toward you becoming foster parents.
___________________________________________________
___________________________________________________
___________________________________________________

Describe your personalities and attitudes toward children:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Describe your attitudes and practices toward child discipline and corporal punishment (spanking, slapping mouths, etc.); How do you discipline you own children:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Describe any prior experience youhave in caring for, supervising, or teaching children:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

How do you feel about a child of another religion and/or culture being placed in your home?
___________________________________________________
___________________________________________________
___________________________________________________

Describe any prior experience in working with children with special needs, such as physical handicaps and emotional disturbances:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Do you wish to work with children with special needs as described above?
___________

Descibe your perceived ability to accept and respect a child as he is:
___________________________________________________
___________________________________________________
___________________________________________________

Describe your perceived ability to accept a foster child's parents and work with them toward the return of your foster children to their natural homes:
___________________________________________________
___________________________________________________
___________________________________________________

Describe your perceived ability to work with the Agency in planning and managing your foster child/children's care.
___________________________________________________
___________________________________________________
___________________________________________________

How many foster children do you feel could successfully live with your family?
______________________

What age group of foster children would you prefer?
____________________________________________

Do you prefer boys, girls, or have no preference?
_____________________________________________

Describe your ability to care for the needs of a client as well as of your biological children:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Describe your ability to meet the changing needs of a client over the course of a placement.
___________________________________________________
___________________________________________________
___________________________________________________

Describe your perceived ability to provide continuity of care throughout a client's placement.

Describe the characteristics of children who would be best suited to your family:
___________________________________________________
___________________________________________________
___________________________________________________

Describe your home surroundings, and neighborhood in which you live. On a separate sheet of paper, draw a layout of your home including the square footage of bedrooms. Draw existing beds in the bedrooms. Write in who sleeps in which bedrooms and where a foster child/children would sleep.
___________________________________________________
___________________________________________________
___________________________________________________

Describe any safety hazards in or around your home:
___________________________________________________
___________________________________________________
___________________________________________________

List any pets that live inside and outside your home (in case of allergies):
___________________________________________________
___________________________________________________

Describe any cigarette, cigar, or pipe smoking in your home (in case of allergies):
___________________________________________________
___________________________________________________

Describe any use of alcohol in your home. Has the use of alcohol ever created a problem for any member of your family. Include any charges or traffic violations while under the influence of alcohol. (This information is needed for placement of children with substance abuse problems):
___________________________________________________
___________________________________________________
___________________________________________________

Describe any use of drugs in your home. Has any family member ever used illegal drugs or abused prescription drugs?
___________________________________________________
___________________________________________________

Describe what toys, recreational equipment, and facilities are available in or near your home:
___________________________________________________
___________________________________________________
___________________________________________________

Describe the quality of your housekeeping and sanitation: ___________________________________________________ ___________________________________________________ ___________________________________________________

Medical care: Family Doctor:_______________________________ Address:____________________________________
Telephone number:___________________________

Family Dentist:_______________________________
Address:____________________________________
Telephone number:___________________________

Hospital used for emergency treatment: _______________________________________
Local school district:___________________________

Local Elementary school:_______________________

Local Middle school:___________________________

Local Junior High School:_______________________

Local High School:_____________________________

If you currently have children in school, describe your working relationship with school personnel.
___________________________________________________
___________________________________________________
___________________________________________________

Family background: Attach extra sheets of paper for this information. Write a life story describing your family backgrounds including number of children, quality of family relationships, and any significant information which will help us know your family background. Describe your family life growing up and your adult life. Describe what happened in your life to lead you to the decision of applying to become foster parents. The wife and husband need to write separate stories. Education: List high school, any college, training/technical school, dates of graduation; and degrees held.

Wife: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Husband: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Work Experience: List all employers, addresses, positions held, dates of employment, and reasons for leaving.

Wife: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Husband: ___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Dependability: List five references (excluding relatives) with complete addresses and telephone numbers:

1. ___________________________________________________

2. ___________________________________________________

3. ___________________________________________________

4. ___________________________________________________

5. ___________________________________________________

If either parent ever received workman's compensation, please explain. If neither did, please write "None"
___________________________________________________
___________________________________________________
___________________________________________________

If any family members have any physical or mental health problems which could interfere with their ability to care for a child/adult in your home, please explain. Please include all psychiatric hospitalizations and treatment including medications for mental disorders. If there are no such problems, please write "None"
___________________________________________________
___________________________________________________
___________________________________________________

Marital History: List marital history for both parents including dates of marriages, separations, divorces, deaths, and names of spouses. It is important to have a stable marriage with no separations for at least two years to be approved for foster parenting (exception if married less than two years).
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Family stability: Describe your relationship with your own children, level of happiness/satisfaction within the family, your expectations for your children, and your preferred methods of reward and punishment.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

If any family members were ever convicted of a crime, please explain. If no one was ever convicted of a crime, please write "None".
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________

Families must not depend on foster care payments to meet the basic needs for their families. Please list total annual family gross income for the last three years (begin with most current): $____________, $_____________, $_____________

Describe your relationship with your relatives, friends, and neighbors:
___________________________________________________
___________________________________________________
___________________________________________________

Church and community affiliations:
___________________________________________________
___________________________________________________

Religious preference: ______________________________

Describe your church affiliation:
___________________________________________________
___________________________________________________

List participation in any other community activities and /or organizations for all family members:
___________________________________________________
___________________________________________________
___________________________________________________

Please describe any areas where you feel that you would especially need guidance and/or support.
___________________________________________________
___________________________________________________
___________________________________________________

Please list any other information that you believe would be helpful to the agency in making a determination about your ability to provide high quality foster parenting.
___________________________________________________
___________________________________________________
___________________________________________________

I certify that the information provided on this application is accurate. I give the Agency permission to contact my previous employers, references, and family physician. This agency can release this information to others upon request.

Wife's signature: ____________________________________
Date:____________

Husband's signature: _________________________________
Date:____________

Attach:
1. Drawing of layout of your home.
2. Copy of driver's license for both parents.
3. A life story for both wife and husband.

Visitor Comments (1)
Adding your comments contributes to the adoption community. Please keep all comments on topic and civil. Visitors are invited to comment and vote for or flag comments based on appropriateness and helpfulness. All comments must adhere to our commenting rules and are subject to moderation.
evangelin porter - 1 year ago
0 0 0
i will love to be a foster parent lost my baby a yr ago #1
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