Names Address Home Telephone HOUSEHOLD MEMBER ONE: DOB Ethnicity Gender Work Phone Cell Phone Is it ok to contact you via these #'s?YesNo If only one, which?WorkHome HOUSEHOLD MEMBER TWO DOB Ethnicity Gender Work Phone Cell Phone Is it ok to contact you via these #'s?Yes No If only one, which?WorkHome CHILDREN ALREADY IN YOUR FAMILY Name DOB Gender Birth Adopted Foster Guardian Name DOB Gender Birth Adopted Foster Guardian Name DOB Gender Birth Adopted Foster Guardian Name DOB Gender birth Adopted Foster Guardian CHARACTERISISTICS OF CHILD DESIRED FOR FOSTER PLACEMENT Male Female Either Both # of Children Ages:0-2 3-6 7-10 11-14 15-18 SPECIAL NEEDS OF A CHILD YOU WILL CONSIDER Behavioral Issues History of Sexual Abuse Learning Disabilities Mental Health Issues Mental Illness of Parents Developmental Delays LEVEL OF LEGAL RISK FOR CHILD TO BE REUNIFIED Low Legal Risk Moderate Legal Risk High Legal Risk ARE YOU LISCENSED FOR FOSTER CARE?YesNo COUNTY/AGENCY
