Prospective Foster Parent Application

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Applicant #1 Name

First Name *

Last Name *

Applicant #2 Name

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

County

Home Phone

Cell Phone

Work Phone

ext Extension

Email Address

Current Marital Status

Married
Single
Widowed
Divorced

How long have you lived at your current address? (If less than 5 years, answer next question)

How many addresses have you had in the last 5 years?

Type of residence

Apartment
Condo
House
Townhouse

How many bedrooms are in your home?

How many are open?

Do you own your home?

Yes
No

If you rent, would a landlord approve of foster children in your residence?

Yes
No

How many of your own children )biological/adopted/step) under the age of 18 live in your home?

List names and ages of the children

Are any of these children specialized?

Yes
No

If yes, states the needs of the specialized children

Do any adults reside in your home?

Yes
No

If yes, list relationship and ages

Do you own a vehicle, drive and have a valid Illinois driver's license and automobile insurance?

Yes
No

If married, do both have above?

Yes
No

Are you currently licensed as a foster parent?

Yes
No

If yes, with what agency? Include address and contact person.

If no, have you ever fostered before?

Yes
No

What are the years you were licensed?

Do you currently have children placed in your home?

Yes
No

If yes, how many?

What is the status of the children placed in your home? (adoption, return home, etc)

How many children have you fostered?

What happened to them? (return home, guardianship, 14 day notice)

If a 14 day notice, what happened? Have you ever had your home on hold?

Have you fostered any children besides the ones described above?

Yes
No

Have you ever fostered children with special needs?

Yes
No

What are your reasons behind leaving your current foster agency?

Have you completed Foster Parent Pride?

Yes
No

Do you have a certificate?

Yes
No

What special talents do you think that you possess that have you prepared to foster a child with special needs?

Occupation of Applicant #1

Describe your work schedule

How long have you worked at your job?

If less than 3 years, how many jobs have you held in the past 5 years?

Are you able to provide proof of income in the form of 3 recent pay stubs and tax information from the previous year?

Yes
No

Occupation of Applicant #2

Describe your work schedule

How long have you worked at your job?

If less than 3 years, how many jobs have you held in the past 5 years?

Are you able to provide proof of income in the form of 3 recent pay stubs and tax information from the previous year?

Yes
No

Do you pay your own utility bills (lights, gas, etc)?

Yes
No

If so, will you be able to provide a copy of them to us? They must be in your name.

Yes
No

Why do you want to become a foster parent with UCP Seguin?

What kind of foster child are you interested in working with? (State age range, gender of child and medical/behavioral conditions)

How did you hear about foster care opportunities at UCP Seguin?

If Other, Please Indicate Where

If Referred By Employee, Foster Parent or Participant/Family, Please Note Their Name:

Please Type Your Full Legal Name and Date

Prospective Foster Parent Application

Applicant Information

Home Information

Family Information

Vehicle Information

Experience

Employment Information

Additional Information

Disclaimer And Signature