Thank you for applying to become a foster parent. We know that the decision to bring other children into your home is not always an easy one. To simplify the application, we have divided the form into sections regarding the husband, wife, family, and references, followed by signatures.
If any questions do not fit you or your family, mark the answer as N/A.

Today's Date*

Family Name (ex. Smith or Jones)*

Physical Address*

Mailing Address (if different from above)

Phone Number*

Please answer the following questions in regard to the husband in the family.

Husband-Full Name*

Husband-Date of Birth *

Husband-Birthplace*

Husband-Date Moved to Richmond County*

Husband-Social Security Number*

Husband-Race *

Black/African American Native American Asian/Pacific Islander White Multi-racial N/A

Husband-Religion *

Husband-U.S. Citizen*

Yes No In progress of Nationalization N/A

Husband-Highest Level of Education *

Some High School High School Diploma/GED Some College Associate Degree Bachelor's Degree Master Degree Doctorate N/A

Husband-Occupation*

Husband-Place of Employment*

Husband-Dates of Employment*

Husband-Annual Income*

Husand-Previous Employer*

Please answer the following question in regard to the wife of the family.

Wife-Full Name*

Wife-Date of Birth*

Wife-Date moved to Richmond County*

Wife-Social Security Number*

Wife-Race*

Black/African American Native American Asian/Pacific Islander White Multi-racial N/A

Wife-Religion*

Wife-U.S. Citizen*

Yes No In progress of Nationalization N/A

Wife-Highest Level of Education*

Some High School High School Diploma/GED Some College Associate Degree Bachelor's Degree Master Degree Doctorate N/A

Wife-Occupation*

Wife-Place of Employment*

Wife-Dates of Employment*

Wife-Annual Income*

Wife-Previous Employer*

Please answer the following questions regarding your family. Please answer the questions thoroughly and honestly. This application is a confidential document.

Name anyone who currently lives in your Home.
Ex. Name, Date of Birth, Relationship; Name, Date of Birth, Relationship*

Date of Marriage*

Place of Marriage*

Have you filed for bankruptcy in the past seven (7) years? If yes, please explain.*

Have you ever been convicted of a crime other than a minor traffic violation? If yes, please explain.*

Do you live in a house, apartment, or other?*

House Apartment Other

What school district do you live in? *

Is your home on:*

Public water and sewer system Well and septic tank Public water and septic tank

Have you ever had a foster child before? If so, when and where did you live at that time? *

Have you ever had any involvement with DSS before? If yes, please explain.*

Family Doctor's Name and Phone Number*

Are you willing to be a foster parent for the following children?
Check all that apply.*

Children of my own race Children of another race Children under the age of 6 Children between the ages of 7-12

Children between the ages of 13-18 Children with emotional or behavioral problems or learning disorders Children with special medical needs

What is your philosophy towards discipline? Discuss methods of discipline that you will use. *

How will you help children placed in your home to develop self-esteem?*

Will children placed in your home be allowed to express themselves openly? Please describe how this might look in your home. *

How will you meet the social needs of a child placed in your home?*

How many children are you willing to take into your home?*

Do you have reliable transportation?*

Yes No

How did you hear about foster parenting?*

What made you decide to become a foster parent?*

Please give specific directions to your home. *

The following four prompts will ask you for the names, addresses, and telephone numbers of people we may contact for references. For best results, please contact these individuals and ask permission to use them as a reference.

Reference #1
Name, Address, and Phone number*

Reference #2
Name, Address, and Phone number*

Reference #3
Name, Address, and Phone number*

Reference #4
Name, Address, and Phone number*

Husband-By selecting the “I agree” choice, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I agree that the information contained within the document is honest and truthful. I further agree that my signature on this document is as valid as if I signed the document in writing. *

I agree I disagree N/A

Wife-By selecting the “I agree” choice, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I agree that the information contained within the document is honest and truthful. I further agree that my signature on this document is as valid as if I signed the document in writing.*

I agree I disagree N/A