Diane, Dane County

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Foster Care Application

Name: Community Care Resources
Address: 6716 Stone Glen Dr., Middleton, WI, 53562, US
Telephone: 800.799.0450
Price range: $$

Please complete the initial application so we can get to know you as a prospective foster parent. If you have any questions, please contact Jane. 608-445-3879.

Applicant # 1:
Name
Last First Middle Maiden
Previous Names and/or Aliases:
Current Address
Street Address City State Zip Code
County:*
How long at current address*
This field is hidden when viewing the form
Previous Address - If less than 5 years at current address
Street Address City State ZIP / Postal Code
Previous Address - If less than 5 years at current address
Street Address City State County ZIP / Postal Code
Date of Birth:*
Month
Day
Year
Race:
Gender:*
Level of Education Completed:*
Email:*
Cell Number:*
Married:*
- Yes
- No
If Yes, Date of current marriage:
Month
Day
Year
Previous Marriage:*
- Yes
- No
From - To Ex-Spouse Full Name From - To Ex-Spouse Full Name
Applicant # 2:
Name
Last First Middle Maiden
Address
Street Address City State Zip Code
County:
How long at current address
This field is hidden when viewing the form
Previous Address - If less than 5 years at current address
Street Address City State ZIP / Postal Code
Previous Address - If less than 5 years at current address
Street Address City State County ZIP / Postal Code
Date of Birth:
Month
Day
Year
Race:
Gender:
Level of Education Completed:
Email:
Cell Number:
Married:
- Yes
- No
If Yes, Date of current marriage:
Month
Day
Year
Previous Marriage:
- Yes
- No
From - To Ex-Spouse Full Name From - To Ex-Spouse Full Name
Children Living in your Household:
Name of Child (First, Middle, Last) DOB Race Gender Relationship to Applicant Grade in School Shared Custody
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1. Name of child (First, Middle, Last):
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DOB:
MM slash DD slash YYYY
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Race:
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Gender:
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Relationship to Applicant:
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Grade in School:
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Shared Custody:
- Yes
- No
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2. Name of Child (First, Middle, Last):
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DOB:
MM slash DD slash YYYY
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Race:
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Gender:
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Relationship to Applicant:
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Grade in School:
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Shared Custody:
- Yes
- No
This field is hidden when viewing the form
3. Name of child (First, Middle, Last):
This field is hidden when viewing the form
DOB:
MM slash DD slash YYYY
This field is hidden when viewing the form
Race:
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Gender:
This field is hidden when viewing the form
Relationship to Applicant:
This field is hidden when viewing the form
Grade in School:
This field is hidden when viewing the form
Shared Custody:
- Yes
- No
This field is hidden when viewing the form
4. Name of child(First, Middle, Last):
This field is hidden when viewing the form
DOB:
MM slash DD slash YYYY
This field is hidden when viewing the form
Race:
This field is hidden when viewing the form
Gender:
This field is hidden when viewing the form
Relationship to Applicant:
This field is hidden when viewing the form
Grade in School:
This field is hidden when viewing the form
Shared Custody:
- Yes
- No
Other Adults/Adult Children Living in your Home:
Other Adults/Adult Children Living in your Home:
Name of adult (First, Middle, Last): DOB: Race: Gender: Relationship to Applicant:
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1. Name of adult (First, Middle, Last):
This field is hidden when viewing the form
DOB:
MM slash DD slash YYYY
This field is hidden when viewing the form
Race:
This field is hidden when viewing the form
Gender:
This field is hidden when viewing the form
Relationship to Applicant:
This field is hidden when viewing the form
2. Name of adult (First, Middle, Last):
This field is hidden when viewing the form
DOB:
MM slash DD slash YYYY
This field is hidden when viewing the form
Race:
This field is hidden when viewing the form
Gender:
This field is hidden when viewing the form
Relationship to Applicant:
List ALL bedrooms in your home. Indicate where everyone in your household sleeps and where prospective foster children will sleep.
Bedrooms:*
Room Dimensions (example 10x12) Location (Floor) Occupied by:
Pets:
Species & Name Age Describe Temperament with Children
Applicant #1
Applicant #1 Employer:
Job Title:
Complete Address
Street Address City
Length of Employment:
From:
Month
Day
Year
To:
Month
Day
Year
Days of the week you work.
Hours Worked:
From:

: Hours

Minutes
To:

: Hours

Minutes
Previous Employment: Please go back 5 years
Employer Name & Address Job Title Employment Dates
Applicant #2
Applicant #2 Employer:
Job Title:
Address
Street Address
Length of Employment:
From:
Month
Day
Year
To:
Month
Day
Year
Days of the week you work.
Hours Worked:
From:

: Hours

Minutes
To:

: Hours

Minutes
Previous Employment: Please go back 5 years
Employer Name & Address Job Title Employment Dates
If applicants are employed, what plans do you have for supervision of children in your care while you are working? Consider before & after school, and summer break.*
Schools for your Home Address:
Elementary School*
Name
Complete Address*
Address
Middle School
Name
Complete Address
Address
Junior High School
Name
Complete Address
Address
Senior High School*
Name
Complete Address*
Address
Parochial or School Choice
Name
Address
Address
List Any Religious or Community Organizations you and/or your family belong to:
As a child placing agency, we assume responsibility for placing children in secure, healthy family situations. The information requested below will help us determine the suitability of placing children in your home. Answering “yes” to any question below will not necessarily disqualify you from being considered. Providing false information on this form is grounds for certification/licensure denial or revocation.
Have you or anyone in your family experienced any of the following:
Check Yes or No:
Physical/Health Issues*
- Yes
- No
- Physical/Health Issues *
List who, what, and dates of occurrence:*
Emotional/Mental Health Issues*
- Yes
- No
- Emotional/Mental Health Issues*
List who, what, and dates of occurrence:*
Alcohol or Drug Use*
- Yes
- No
- Alcohol or Drug Use*
List who and frequency of consumption*
Therapy/Counseling*
- Yes
- No
- Therapy/Counseling *
List who and dates of occurrence:*
Marital/Relationship Problems*
- Yes
- No
- Marital/Relationship Problems *
Dates of Occurrence:*
Parent-Child Problems*
- Yes
- No
- Parent-Child Problems *
List who and Dates of Occurrence:*
Medications*
- Yes
- No
- Medications *
List who and Date of Occurrence:*
Financial Problems*
- Yes
- No
- Financial Problems *
List who and Date of Occurrence:*
Child-School Problems*
- Yes
- No
- Child-School Problems *
List who and Date of Occurrence:*
Sexual Abuse*
- Yes
- No
- Sexual Abuse *
List who and Date of Occurrence:*
Physical Abuse*
- Yes
- No
- Physical Abuse *
List who and Date of Occurrence:*
Has anyone in your family/household had contact with law enforcement in the past 8 years?*
- Yes
- No
Who / When / Briefly explain*
Has anyone in your family/household ever been arrested for a felony?*
- Yes
- No
- Legal Proceedings still in progress
Who / When / Briefly explain, including final conviction*
Has anyone in your family ever been in foster care?*
- Yes
- No
Who / When:
Does anyone in your household have a concealed carry permit?*
- Yes
- No
Who:
Does anyone in your household smoke?*
- Yes
- No
Who:
Please write N/A if the below question does not apply:
Have you ever applied for a foster care or day care license with another agency? If yes, when and what agency?*
For all previous foster care experience, give the name of the agency, dates, and reason you are no longer with agency.
Have any of your children ever been involved in the juvenile system (Human Services, Court system)? If yes, briefly explain.*
Have you and your spouse/partner ever had marital problems (separation, divorce, domestic disturbance, counseling)? If yes, briefly explain.*
Describe your use of any alcohol, drugs, and/or chemicals and how they affect you?*
How might you and your family benefit from caring for foster children?*
What can you and your family can offer foster children?*
Describe the age range, gender, and other particulars of the type of foster children you wish to care for.*
Please describe the age range and type of child or behaviors you wish NOT to care for:*
If you have children of your own describe the methods of discipline used:
If you do not have children of your own, what methods of discipline do you feel are appropriate for children?
Explain how caring for and disciplining foster children may be different from your own child(ren)?
Describe all experience you have with children. Mentoring, volunteering, teaching, coaching, counseling, etc.*
I, the applicant named below, agree to provide Community Care Resources with sufficient information to verify that licensing requirements are met. I further authorize Community Care Resources to investigate as is necessary for verification including access to my home or records regarding the children placed in my home. I understand that this may include Community Care Resources reviewing social media accounts and other available online internet sources. By typing my signature below, I understand that it constitutes a legal signature confirming that I acknowledge and agree to the above terms.
Applicant #1*
By typing or signing my name below, I understand that it constitutes a legal signature that I acknowledge the information provided above to be truthful and accurate.
Date*
Month
Day
Year
Applicant #2
By typing or signing my name below, I understand that it constitutes a legal signature that I acknowledge the information provided above to be truthful and accurate.
Date
Month
Day
Year