Foster / Adoption Pre Qualification form

Personal and contact information.
Fields marked (*) are required

* First Name:
Required Field.
* Last Name:
Required Field.
* Age:
A value is required.Invalid format.
Co-Applicant First Name:
Co-Applicant Last Name:
Co-Applicant Age:
* Street Address:
Required Field.
* City:
Required Field.
* State:
Please select a valid state.Please select an item.
* Zip Code
Required Field.Invalid format.

* Home Phone:
(ex) 123-456-7890
A value is required.

Work Phone:
Work Ext:

Cell Phone:


Pre Qualification Questions

1. Including yourself, how many people live in your house?
Adults:     Children:
2. What are their ages and gender? (If its just you that resides in the home, leave blank)

3. How many bedrooms do you have in your home?
4. A foster child must have their own bed/crib in a room with at least 45 square feet with a window.
    Do you have such accomodations?
5. Are you interested in:
6. What type of child would you like to foster/adopt.
     Age:   Sex:
7. Would you like children with special needs (Medical, Behavorial, Educational, Psychiatric)?
8. Appointments for children can be as often as weekly. These include family visiting,
     medical or therapy appointments. Are you able to transport to and from these appointments?
9. Yearly income:
10. How many hours per week do you work?
* 11. What is your Occupation?
      Please name your occupation.
12. Appointments and training classes can be in the daytime or evenings. Which one would you prefer?
13. Have you ever been with another Foster Care agency?
14. If yes, name of agency