Therapeutic Foster Care Parent Application Today's Date* MM DD YYYY Name of Prospective Mother*Age*Name of Prospective Father*Age*Length of Marriage*If ApplicableAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone: Mother*Cell Phone: Father*Home Phone*Work Phone*Email* Children in the Home*Please list all children's names and ages.Name of ChildAge Interested in Fostering:*Age(s)GenderEthnicity About Perspective Parents & HomeAre both prospective parents employed?*YesNoName of Employer*Length of Employment*Employer Phone*Name of Second Parent's Employer*Length of Second Parent's Employment*Second Parent's Employer Phone*What prompted your interest in becoming a Therapeutic Foster Care Parent?*Is your home in good repair?*Is your home kept clean?*How many bedrooms and people per bedroom are currently in your home?*How many bathrooms are in your home?*How many people are currently living in your home?*Please list the age and gender of each person living in your home.AgeGender Additional Information:Please add other important information not already mentioned.Strengths & Needs ChecklistDo you have current certifications in CPR and First-Aid?*YesNoAre you willing to take classes to be certified in Adult/Child CPR and basic first-aid?*YesNoIs there adequate bedroom space for the child and those that are currently residing in the home?*YesNoIs there adequate drawer and closet space in the bedrooms?*YesNoIs there adequate play space (inside and outside)?*YesNoIs there adequate living space for all family members?*YesNoAre firearms kept unloaded and locked away?*YesNoN/AIs ammunition stored separately and locked way?*YesNoN/AAre harmful substances such as ammonia based household cleaning products stored appropriately?*YesNoAre necessary safety precautions taken regarding swimming pools, trampolines, weight lifting equipment, four wheelers, etc.?*YesNoN/AAre there working smoke detectors near each bedroom?*YesNoIs there a fire extinguisher in the kitchen?*YesNoAre all medications locked away or out of reach?*YesNoDo you have adequate first-aid supplies?*YesNoAre safety drills conducted monthly?*YesNoWill the child have adequate care during the summer?*i.e. taken to day care, transported to a summer camp, or remain in the homeYesNoCan you commit to completing the necessary paperwork?*YesNoCan you commit to a meeting with the program manager once a week or at least every other week?*YesNoCan you attend a service team meeting once a month for each child in your home?*YesNoCan you transport the child when necessary to appointments, school, service team meetings, or therapy sessions?*YesNoWill you be able to respect the cultural, ethnic, and religious differences of the child?*YesNoWill you collaborate with teachers, biological parents, and service team members as needed?*YesNoCan you commit to 24 hours yearly of additional training?*YesNoCan you say that money will not be the major factor in the decision to become a Therapeutic Foster Care Parent?*YesNoWill you accept a child that may have severe behavioral or emotional problems?*YesNoCan you commit to having a list of rules and consequences that everyone must follow regardless if the child is biological or fostered?*YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.