< Return to Treatment Foster Care General InformationYour Name (required) Address (required) City (required) State (required) AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code (required) Birth Date (required) Birth Place (required) Your Phone (Home) Your Phone (Work) Your Phone (Mobile) Your Email (required) Are You a High School Graduate (required) YesNo Employment Are you currently employed? (required) YesNo If yes, current employer Household Composition Marital Status (required) SingleMarriedDivorcedWidowed Please list all of the members of your household (including yourself) Please include: Name, Birth Date, Gender, and relationship.(required) Foster Care Information Have you ever participated in foster care training with another agency? (required) YesNo If yes, explain If you have ever been certified as a foster parent for another agency in this state or another state, provide the following information:Name of agency Address Phone Number Are you currently certified? YesNo May we contact this agency? YesNo Why do you want to be a Treatment Foster Parent to a child with special needs? Please list any specialized training or experience which has prepared you to serve children with special needs: What type of child with special needs will your family best be able to provide care to? How did you hear about The Arc NCR’s Treatment Foster Care Program? Signature“I hereby certify that all of the above responses are true and correct. I understand that any false or misleading statements made as part of this application may be cause for non-acceptance into The Arc Northern Chesapeake Region’s Treatment Foster Care Program.”Signature Date < Return to Treatment Foster Care