Foster Care Application

Your 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

Are you currently employed? (required)
YesNo

If yes, current employer

Marital Status (required)
SingleMarriedDivorcedWidowed

Please list all of the members of your household (including yourself) Please include: Name, Birth Date, Gender, and relationship.(required)

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?

“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