Foster / Adoption Pre Qualification form
Fields marked (*) are required
First Name:
*
Last Name:
*
Age:
*
Spouse First Name:
Spouse Last Name:
Spouse Age:
Street Address:
*
City:
*
State:
*
Zipcode:
*
Home Phone:
*
(ex) 123-456-7890
Work Phone:
Work Ext:
Cell Phone:
E-Mail:
Pre Qualification Questions
*
1. How many people live in your house?
Adults:
1
2
3
4
5
6 or more
Children:
1
2
3
4
5
6 or more
2. What are their ages and gender? (If just you leave blank)
*
3. How many bedrooms do you have in your home?
One
Two
Three
Four
Five
Six
Seven
eight or more
*
4. A foster child must have there own bed/crib in a room with at least
45 square feet with a window. Do you have such accomodations?:
Yes
No
*
5. Are you interested in
Foster Care
Adoption
Both Foster and Adoption
*
6. What type of child would you like to foster/adopt.
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Sex:
Male
Female
*
7. Would you like children with special needs (Medical, Behavorial, Educational, Psychiatric)?
Yes
No
*
8. Appointments for children can be as often as weekly. These include family visiting,
medical or therapy appointments. Are you able transport to and from these appointments?
Yes
No
9. Yearly income:
$0.00 - $10,000
$10,000 - $20,000
$20,000 - 30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $60,000
$60,000 - $70,000
$70,000 - $80,000
$80,000 - $90,000
$90,000 - $100,000
$100,000 - $110,000
$110,000 - $120,000
$120,000 - $130,000
$130,000 - $140,000
$140,000 - $150,000
$150,000 - or above
*
10. How many hours per week do you work?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60 or more
11. What is your Occupation?
12. Appointments and training classes can be in the daytime or evenings. Which one would you prefer?
Day
Evening
*
13. Have you ever been with another Foster Care agency?
Yes
No
14. If yes, name of agency
Contact MercyFirst Web Master
