FOSTER AND ADOPTION APPLICATION

We consider applicants without regard to race, color, religion, sex, national origin, age, marital or veteran status, sexual orientation, gender identity, the presence, the presence of job-impairing medical conditions or handicap, or any other legally protected status.

First and Last Name(s) Home Telephone

Address:City:Zip Code:______

Previous address if less than 10 years at current address:______

include city & zip code

Couples: ____Married ____PartnersSingles: ___Divorced ___Separated ___Widowed ___Single

General informationHow did you hear about Hathaway-Sycamores?

Parent #1/ First Name: Middle Name:

Other Names you have used (Maiden or Aliases):

LastSchool Grade Completed: Ethnicity/Race:

Date of Birth: Place of Birth:

Color of Hair: Color of Eyes:

Height: Weight:

Driver's License #: Social Security #:

Citizenship: Religion:

Have you been a California resident for the past five years?

Occupation: Gross Monthly Income:

Employer Name: Telephone:

Employer Address:

Your Cell Phone Number: ______Email:______

Parent #2/ First Name: Middle Name:

Other Names you have used (Aliases):

LastSchool Grade Completed: Ethnicity/Race:

Date of Birth: Place of Birth:

Color of Hair: Color of Eyes:

Height: Weight:

Driver's License #: Social Security #:

Citizenship: Religion:

Have you been a California resident for the past five years?

Occupation: Gross Monthly Income:

Employer Name: Telephone:

Employer Address:

Your Cell Phone Number: ______Email:______

INFORMATION REGARDING FORMER MARRIAGES

Parent #1

Spouse's Name: Date and Place:

How Terminated: Date and Place:

Spouse's Name: Date and Place:

How Terminated: Date and Place:

Parent #2

Spouse's Name: Date and Place:

How Terminated: Date and Place:

Spouse's Name: Date and Place:

How Terminated: Date and Place:

INFORMATION REGARDING RELATIVES AND THE MEMBERS OF THE HOUSEHOLD

Nearest Relative: Telephone:

Address:

Fingerprints and Child Abuse Clearances are required for everyone over

18 years old living in the home. TB tests are required for all members of the household.

Children in the home

Name / Birthdate / Age / Birthplace / Sex / School Grade

Children out of the home (adults and minors)

Name and Age / Address

Others in the home (adults and minors)

Name / Birthdate / Sex / Relationship

Pets in the home

Name / Species / Name / Species

INFORMATION REGARDING KNOWLEDGE OF CHILDREN

List Education, Experience, and Training that relates to being a foster parent:

Education:

Child Care Experience:

Employment:

REFERENCES (NOT RELATIVES) FAMILIAR WITH YOUR EXPERIENCE WITH CHILDREN

1. Name: Telephone:

Complete Address:

2. Name: Telephone:

Complete Address:

3. Name: Telephone:

Complete Address:

Have you had a prior connection with another Foster Family Agency or been licensed as a foster parent in California or any other State? ___No ___Yes If yes, Agency/County name and address:

Have you ever been decertified, or had a foster care license revoked, or been placed on “hold” by any agency? ___No ___Yes If yes, which agency, and describe circumstance:

Have you ever been approved as a relative caretaker by any agency in any State? ___No ___Yes
If yes, describe:

Have you ever had or do you currently have an open case with the Department of Children and Family Services? ___No ___ Yes If yes, describe:

Please specify children desired:
Male/Female Ethnicity:
Ages desired Number of children you can accept:

Our agency is required by law to conduct reference checks with all agencies, counties, and licensing entities that have previously certified/licensed you as a foster or relative caretaker. Your signature serves as authorization for us to conduct a check of references and previous agencies. Your signature is your declaration that the information submitted here is true, correct, and contains no material omissions of fact to the best of your knowledge and belief. Any person who declares as true any material pursuant to this application that he or she knows to be false is guilty of a misdemeanor. Submitting false information is a violation of law punishable by incarceration, a fine, or both.

Signature of Parent #1: Date:

Signature of Parent #2: Date:

HOUSEHOLD FINANCIAL AND BUDGET INFORMATION

Earnings or income of household members:

Name Source of earnings or income Net per month

TOTAL NET INCOME/EARNINGS PER MONTH $

Household and personal expensesAmount per month

Mortgage or Rent

Groceries/Household expenses

Dining out (average)

Homeowners/Renters Insurance

Child Support (for children not in home)

Alimony

Car payment/lease

Auto insurance

Car Gasoline (average)

Gas, Electric, Water (average)

Cable TV

Phone (average)

Mobile Phone (average)

Medical Insurance

Medical expenses (average)

School tuition

Recreation (average)

Day Care

Clothing (new and upkeep, average)

Credit card payments (please list)

Other monthly expenses

Savings or Investment accounts: ______

Average monthly Balance: ______

TOTAL AVERAGE MONTHLY EXPENSES $

I certify the above information to be true to the best of my knowledge. I understand that this information may be verified, but will also be kept confidential by Hathaway-Sycamores. I also understand that I must report any significant changes in income, earnings and/or expenses if I become certified by Hathaway-Sycamores.

Signature Date:

Signature: Date:

FLOOR PLAN, PROPERTY DESCRIPTION

FOSTER APPLICANT'S NAME(S) :

Please answer the following questions and draw a detailed interior floor plan on this page and an exterior grounds plan of your home and entire property on the next page showing 1) the approximate dimensions of each room; 2) where the exit locations are throughout the home; 3) where you will meet in case of an emergency (indicated by a large “X”); 4) who sleeps in each room and 4) the following emergency features:

EElectricity Shut-offFEFire ExtinguisherFFirst Aide KitsGGas Shut-off SSmoke Detectors

WWater Shut-offHHosesEQEarthquake/Survival Kit

[---] Windows--- FencesC Closets

This is a:

1-storyHouseFenced yardSwimming Pool Jacuzzi

2-story ApartmentYesYes*Yes

Tri-levelMobile homeNoNoNo

# of bedrooms_____*Is pool fenced?

Interior Facility Sketch (Floor Plan of Interior of Home)

Interior Facility Sketch (Floor Plan of Second Floor of Home, if applicable)

Exterior Facility Sketch (Grounds, Yard, Garage, Fencing, etc.)

Hathaway-Sycamores Foster Family Agency ApplicationPage 1 of 10