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Get Involved
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Foster Program Registration
Foster Family - Application Form
Applicant 1
*
First
Middle
Last
Preferred Name
First
Last
Please select your state
*
North Carolina
Foster Care Interest
*
Traditional Foster Care
Short-Term Respite Care
Adoption from Foster Care
Open to Any Opportunity
Traditional - Open to temporary placement of children. That could be short or long-term. Short-term Respite/Emergency placement - Open to short term, temporary placement of children in emergency situations or those in need of respite care. Adoption from Foster Care - Only open to adoptive placement of legaly free children with no interest in fostering.
Have you worked with any foster/adoption agency, home study agency and/or attorney?
Yes
No
If yes, please list contact information
A-1 - Have you ever been turned down by another agency?
Yes
No
A1 -If you have been turned down by another agency, please explain.
A1 - Maiden Name (if applicable)
A1 - Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
A1 - Primary phone contact
*
A1 - May we leave a voice message?
*
Yes
No
A1 - Email
*
A1 - Place of Birth City / State / Country
*
A1 - How long have you lived in your current state of residence?
*
A1 - Date of birth
*
MM slash DD slash YYYY
A1 - Ethnicity (Optional)
Selection Optional
African American
Asian
Indian American
Caucasian
HIspanic
Other
A1 - Last 4 digits of your Social Security Number
*
A1 - Employer
*
A1 - Occupation
*
A1 - Annual Salary in US Dollars
*
A1 - Other Financial Resources (optional)
Please provide other financial resources if applicable.
A1 - Have you ever filed for bankruptcy?
*
Yes
No
A1 - Explain your bankruptcy including dates.
A1 - Are you a U.S. Citizen?
*
Yes
No
A1 - Have you been in a prior marriage?
*
Yes
No
A1 - Have you been separated from your spouse?
*
Yes
No
A1 - List the gender and date of birth of any current children
*
A1 - Have you ever been accused of child abuse, neglect and/or domestic violence?
*
Yes
No
A1 - Please include instances of accusation for child abuse, neglect and or domestic violence. Include dates, city and state
A1 - Are you undergoing any medical treatments?
*
Yes
No
A1 - Please list any medical conditions you are being treated for.
*
A1 - Are you currently being, or have you previously been treated for an emotional condition?
*
Yes
No
A1 - Please list reasons if you have undergoing or have you previously undergone for counceling
A1 - Do you have any history of substance abuse?
*
Yes
No
A1- Explain your substance abuse.
A1 - Have you ever been arrested, have criminal records or convictions?
*
Yes
No
A1 - If Yes, Please include a list of records, dates and include any juvenile or expunged records.
A1 - Are you currently married
*
Yes
No
A1 - Please select your marital status
*
Select Marital Status from the drop down
Married / Never divorced
Married / Previously divorced
Single / Never Married
Single / Divorced
Single / Widowed
A1 - Date of Marriage
MM slash DD slash YYYY
A2 - Applicant 2
*
First
Middle
Last
A2 - Preferred Name
First
Last
A2 - Maiden Name (if applicable)
A2 - Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
A2 - Phone
*
A2 - Email
*
A2 - May we leave a voice message?
*
Yes
No
A2 - Place of Birth City / State / Country
*
A2 - Date of birth
*
MM slash DD slash YYYY
A2 - How long have you lived in your current state of residence?
*
A2 - Ethnicity (Optional)
African American
Asian
Selection Optional
Indian American
Caucasian
HIspanic
Other
A2 - Last 4 digits of your Social Security Number
*
A2 - Employer
*
A2 - Occupation
*
A2 - Annual Salary in US Dollars
*
A2 - Other Financial Resources (optional)
*
A2 - Have you ever filed for bankruptcy?
*
Yes
No
A2 - Please explain the circumstances around your bankruptcy.
A2 - Is Applicant 2 a U.S. Citizen?
*
Yes
No
A2 - Have you been in a prior marriage?
*
Yes
No
A2 - Have you been separated from your spouse?
*
Yes
No
A2 - List the gender and date of birth of any current children if different from above
A2 - Have you ever been accused on child abuse, neglect and/or domestic violence?
*
Yes
No
A2 - Are you undergoing any medical treatments?
*
Yes
No
A2 - Are you currently being, or have you previously been treated for any mental health issues
*
Yes
No
A2 - Do you have any history of substance abuse?
*
Yes
No
A2 - Explain your history of substance abuse.
A2 - Have you ever been arrested, have criminal records or convictions?
*
Yes
No
A2 - Explain your criminal history.
Preferred gender for foster child/children?
*
Female
Male
Open to either
Are you open to sibling groups
*
Yes
No
Number of children you would like to foster (individual or sibling group)
*
Enter the age range of child/children you wish to foster.
*
A2 - Agency information Applicant 2
*
Please list any agency, home study agency and/or attorney contact information (if applicable).
A2 - May we contact your former agency?
Yes
No
A2 - Have you ever been turned down by another adoption agency?
*
Yes
No
A2 - If you have been turned down by another agency - please explain.
Please share any special skills, interests, or specialized populations that you have interest in working with as a foster parent.
*
Consent
*
I agree to the privacy policy.
