More homes with flexible schedules are needed for young siblings.
COMMUNITY CARE RESOURCES
Providing Hope & Healing for Wisconsin Foster Children
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Single Application
Single Application
Applicant:
Name
First
Last
Middle
Maiden
Previous Names and/or Aliases:
Previous Names and/or Aliases:
Date of Birth:
*
Month
Day
Year
Gender:
*
Race:
Cell Number:
*
Email:
*
Current Address
*
Street Address
City
State
Zip Code
County:
*
Choose your county
Adams
Barron
Brown
Buffalo
Burnett
Calumet
Chippewa
Clark
Columbia
Crawford
Dane
Dodge
Door
Dunn
Eau Claire
Fond Du Lac
Grant
Green
Green Lake
Iowa
Jackson
Jefferson
Juneau
Kenosha
Kewaunee
La Crosse
Lafayette
Manitowoc
Marathon
Marquette
Menominee
Milwaukee
Monroe
Outagamie
Ozaukee
Pepin
Pierce
Polk
Portage
Price
Racine
Richland
Rock
Rusk
St. Croix
Sauk
Sawyer
Shawano
Sheboygan
Taylor
Trempealeau
Vernon
Walworth
Washburn
Washington
Waukesha
Waupaca
Waushara
Winnebago
Wood
How long at current address
*
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
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
Level of Education Completed:
*
Children, 17 years and younger, living in your home:
Name of Child (First, Middle, Last)
DOB
Race
Gender
Relationship to Applicant
Grade in School
Shared Custody
1. Name of child (First, Middle, Last):
DOB:
Race:
Gender:
Relationship to Applicant:
Grade in School:
Shared Custody:
Yes
No
2. Name of Child (First, Middle, Last):
DOB:
Race:
Gender:
Relationship to Applicant:
Grade in School:
Shared Custody:
Yes
No
3. Name of child (First, Middle, Last):
DOB:
Race:
Gender:
Relationship to Applicant:
Grade in School:
Shared Custody:
Yes
No
4. Name of child(First, Middle, Last):
DOB:
Race:
Gender:
Relationship to Applicant:
Grade in School:
Shared Custody:
Yes
No
Other Adults or 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:
1. Name of adult (First, Middle, Last):
DOB:
Race:
Gender:
Relationship to Applicant:
2. Name of adult (First, Middle, Last):
DOB:
Race:
Gender:
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 (example: 1st Floor, 2nd Floor)
Occupied by:
Pets:
Species & Name
Age
Describe Temperament with Children
Employer:
Job Title:
Employer Complete 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 you are employed, describe your plan for supervising children in your care during work hours, including arrangements for before and after school, school breaks, and summer.
*
Schools for your Home Address:
Elementary School
*
Name
Complete Address
*
Street 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
Please list any religious, community, or civic organizations you are involved in.
As a child-placing agency, we are responsible for ensuring children are placed in safe, stable, and supportive homes. The information requested below will help us assess your readiness and suitability to provide foster care. Answering “yes” to any question does not automatically disqualify you. However, providing false or incomplete information may result in denial or revocation of certification/licensure.
Have you or anyone in your household experienced any of the following:
Check Yes or No:
Physical/Health Issues
*
Yes
No
List who, what, and dates of occurrence:
*
Emotional/Mental Health Issues
*
Yes
No
List who, what, and dates of occurrence:
*
Alcohol or Drug Use
*
Yes
No
List who and frequency of consumption
*
Therapy/Counseling
*
Yes
No
List who and dates of occurrence:
*
Relationship or Marital Challenges
*
Yes
No
Dates of Occurrence:
*
Parent-Child Problems
*
Yes
No
List who and Dates of Occurrence:
*
Medications
*
Yes
No
List who:
*
Financial Problems
*
Yes
No
List who and Date of Occurrence:
*
Child-School Problems
*
Yes
No
List who and Date of Occurrence:
*
Sexual Abuse
*
Yes
No
List who and Date of Occurrence:
*
Physical Abuse
*
Yes
No
List who and Date of Occurrence:
*
Have you or anyone in your household had contact with law enforcement in the past 8 years?
*
Yes
No
Who / When / Briefly explain
*
Have you or anyone household ever been arrested for a felony?
*
Yes
No
Legal Proceedings still in progress
Who / When / Briefly explain, including final conviction
*
Have you or 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:
If a question does not apply to you, please type “N/A” in the answer field.
Have you ever applied for a foster care, adoption, or day care license with another agency?
*
Yes
No
please list the agency, approximate dates, and the outcome of your application
*
Do you have any previous foster care experience?
*
Yes
No
please list the agency, approximate dates, and reason(s) for no longer fostering with each agency
*
Have any of your children ever been involved with the juvenile justice system or child welfare services ?
*
Yes
No
I have no children
Briefly explain
*
Describe your current and past use of alcohol, drugs, or other substances, including frequency and any history of concerns or treatment.
*
How might you and your family benefit from caring for foster children?
*
Describe the support systems you would rely on while caring for a foster child, including family, friends, and community resources.
*
Describe the age range, gender, and specific needs or characteristics of the foster children you feel best prepared to care for.
*
Please describe the age ranges, behaviors, or specific needs you do not feel prepared to care for at this time.
*
If you have children, describe the discipline strategies you use. Provide specific examples of how you respond to challenging behaviors in your home.
If you do not have children, describe the discipline approaches you believe are appropriate when caring for children in a home setting.
When a child in your care is struggling with behavior, describe your typical response. Also explain how you would adapt if different strategies were recommended or required.
*
Describe your experience working with or caring for children (e.g., mentoring, volunteering, childcare, teaching, coaching).
*
I, the applicant named below, agree to provide Community Care Resources with the information necessary to verify that all licensing requirements are met. I authorize Community Care Resources to conduct any inquiries needed for this verification, including access to my home and to records related to children placed in my care, as permitted by law. I understand that this review may include publicly available information, such as social media and other online sources. By typing my name below, I acknowledge and agree to these terms and understand that my typed signature constitutes a legally binding signature.
Applicant
*
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
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6716 Stone Glen Dr.
Middleton, WI 53562
800.799.0450
608-827-7101
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