FOSTER/ADOPTION FAMILY APPLICATION

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1 FOSTER/ADOPTION FAMILY APPLICATION Please check status: Prospective Family Name Name Current Address (City & Zip Code) Home Phone Cell Phone Other Phone Other Phone List Previous addresses in Texas cities where you have lived and out of state in the past 10 years and duration in each location: Directions to current residence from our office at 919 Mission Road: Prospective Parent #1 US Citizen? Driver License: Social Sec. #: Place of Birth: State: Date of Birth: Education Elementary Name, City, State Degree/Major Years/From-To

2 High School College Grad School Trade School Language more comfortable: Reading: Writing: Speaking: Activities and Interests: Present Employment Employer's Address: Phone Number: Occupation: Length of Employment: Military History Branch of Service: Date and Type of Discharge: Are you receiving disability: Injuries in the service: Work hours: Annual Salary: Rank: Health Information Hospitalization of Past Serious Illnesses within the last five years: If yes, please explain and include dates: Current health problems and prescribed medication currently taking: Marital Status Date of Current Marriage: Place Married: Previous Marriages: (Include date, place, and date of termination) Prospective Parent #2 US Citizen? Driver License: Place of Birth: State: Date of Birth:

3 Social Sec. #: Education Elementary High School College Grad School Trade School Name, City, State Degree/Major Years/From-To Language more comfortable: Reading: Writing: Speaking: Activities and Interests: Present Employment Employer's Address: Phone Number: Occupation: Length of Employment: Military History Branch of Service: Date and Type of Discharge: Are you receiving disability: Injuries in the service: Work hours: Annual Salary: Rank: Health Information Hospitalization of Past Serious Illnesses within the last five years: If yes, please explain and include dates: Current health problems and prescribed medication currently taking: Marital Status Date of Current Marriage: Place Married: Previous Marriages: (Include date, place, and date of termination) Children in the home (17 years old and younger)

4 Name Date of Birth Social Sec. # School/Occupation Others in the home Name Date of Birth Relationship Social Sec. # School/Job Children out of the home Name Age Phone Number Address, City, State, Zip Name, address, and phone number of your physician and pediatrician: Schools in your neighborhood: Elementary: Middle: High School: Emergency Contact Information Relationship: Phone Number General Information: Please provide general information about your experience with children Have you applied to another foster agency, been a foster parent with, or been denied by another foster agency before? If yes, please name the agency and explain. Are you currently verified as a foster home? If yes, name the agency

5 Please indicate the type of child you will and will not consider: Infants (0-2) Pre-school(3-5) School Age(6-12) Adolescent (13-17) Autistic Mentally Retarded Developmentally Delayed Physically Handicapped Down Syndrome Seizure Disorder Sibling group size (up to 5): Grievance Procedure A prospective foster parent applicant who submits an application and engages in the process to include required training and the home study process is not guaranteed acceptance by St. PJ's to provide foster care to children placed through St. PJ's Children's Home. Foster parent applicants have the right to appeal a decision made by St. PJ's Children's Home that directly impacts them or their ability to provide care for the agency. The grievance procedure has several levels for review but the grievance may be resolved at any point in the process. I certify the information in this application is accurate and complete. We understand that submitting this application does not represent a commitment by any of the parties involved. If your application is denied you have the right to appeal the decision. I have read and understand the grievance procedure stated above. Signature of Prospective Parent Date Signature of Prospective Parent Date

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