Foster Parent Application - Apelah

Foster Parent ApplicationDownload this form, fill it out on Adobe PDF, save your changes, and email to [email protected]

Applicant *

First Name Middle Name Last Name

SSN

xxx-xx-xxxx

Date of Birth

MM/DD/YYYY

Spouse (if applicable)


SSN

xxx-xx-xxxx

Date of Birth

MM/DD/YYY

Address *

Street Address

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

APPLICANT INFORMATION

Last Grade CompletedGender Race/Ethnicity Religious Affiliation

Marital status Date of Marriage

Month Day Year

Date Marriage Ended

Month Day Year

Have you been previously married?

YesNo

Reason

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End

Year

Have you served in the Military?

YesNo

Start

Year

Were you ever convicted by a General Court-Martial

YesNo

Occupation Annual IncomeEmployer

Work Phone Number


Emergency Number


CO-APPLICANT INFORMATION

Last Grade CompletedGender Religious AffiliationRace/Ethnicity

Marital Status Date of Marriage

Month Day Year

ReasonHave you been previously married?

YesNo

Date Marriage Ended

Month Day Year

End

Year

Were you ever convicted by a General Court-Martial?

YesNo

Have you served in the Military?

YesNo

Start

Year

Annual IncomeEmployerOccupation

Emergency Number


Work Phone Number




CHILDREN IN THE HOME

Date of Birth

MM/DD/YYYY

Name RelationshipSex Grade or Occupation

RelationshipGrade or OccupationSexName Date of Birth

MM/DD/YYYY

RelationshipSexDate of Birth

MM/DD/YYYY

Grade or OccupationName

CHILDREN OUT OF THE HOME

RelationshipGrade or OccupationSexDate of BirthName

RelationshipGrade or OccupationSexName Date of Birth

RelationshipSex Grade or OccupationName Date of Birth



Have you had previous involvement with any foster care agency?

YesNo

If yes, please summarize your involvement and the time frame during which it took place:

Have you previously applied to be a foster parent with another agency?

YesNo

If yes, when and with what agency?

TYPE OF CHILD YOU HOPE TO FOSTER

Sex

Female Male Either

Age Range

yougest - oldest

Are you willing to take a sibling group?

Yes No

If yes, how many children would you consider fostering at this time?

Would you be willing to accept a child (please check all that apply):

with behavioral problems with conduct disorderswith exposure to drugs/substance abuse with extensive medical equipmentwith emotional disturbance with intellectual/developmental disabilitieswho has been physically abused



Race/Ethnicity (Choose one or more codes)

AA (African American) AI (American Indian) AS (Asian)CA (Caucasian) HI (Hispanic) Any racial or ethnic heritage

Note: By the end of the preparation process, the description of the child you hope to foster may change. If so, you willhave the opportunity to redefine the child you feel you can most successfully parent. As a foster parent, you areencouraged to update this information as you continue to redefine the child you wish to parent.

Legal Information

Applicant: Are you currently charged with, or have you ever been convicted, placed on probation, or received a suspended sentence for (check all that apply):

Any crime involving childrenAny crime of violence against another personPossession, sale, manufacturing, or transportation of drugsAny other crime

If you answered "other crime," please explain:

Co-Applicant: Are you currently charged with, or have you ever been convicted, placed on probation, or received a suspended sentence for (check all that apply):

Any crime involving childrenAny crime of violence against another personPossession, sale, manufacturing, or transportation of drugsAny other crime

If you answered "other crime," please explain:

This application is a statement of intentions and can be withdrawn by the applicant at any time. I (We) the applicant(s)_____consent to the release of our names for the mailing list of foster parent associations, training, and newsletters.

dodo not



References

Signature of applicant(s) authorizes Apelah to contact the references listed on the application form andauthorizes said references to respond to the inquiry.

If you are filling out and sending this application electronically, checking this box indicates authorization

Applicant Co-Applicant

DatePrinted Name of Applicant Signature

DateSignaturePrinted Name of Co-Applicant

Please list personal references: one (1) workplace reference (if applicable) for eachapplicant, plus three (3) other references.

Applicant Name

First Name Last Name

Phone Number


Co-Applicant Name


Phone Number


Applicant Workplace Reference

OccupationName


Relationship to Applicant

Phone Number


Address



Co-Applicant Workplace Reference

OccupationName


Relationship to Co-Applicant

Phone Number


Address

Non-Relatives

Name


OccupationRelationship to Applicant

Phone Number


Address

Name



Address Phone Number


Name



Phone Number


Address



Apelah Discipline Policy

Discipline is a training process through which a child develops the self control, self-reliance, and orderly conductnecessary to assume responsponsibilies, make daily living decisions and live according to accepted levels of of socialbehaviors. The goals of discipline for foster children are:

1. To problem-solve appropriate ways of getting needs met (i.e. for attention, ways to express feelings, etc.)2. To feel good about relationships with other adults and other children.3. To have a positive self-concept

In order to accomplish these goals, the following guidelines should be followed:

1. All discipline must be reasonable and responsibly related to the child's understanding, need, and level of behavior.All discipline shall be limited to the least restrictive appropriate method and administered in an appropriatemanner.

2. Encouragement and praise of good behavior is often more effective than punishment and is a must in disciplininga child. The child's acceptance of discipline and ability to profit by it depends largely upon feeling that he/she isliked, accepted, and respected.

3. Any discipline must be determined on an individual basis and be related to the undesirable behavior. Requiringchildren to accept the natural consequences of their acts may be a desireable experience, providedconsequences are not too drastic.

The following form of punishment must not be used :

1. Corporal punishment, such as slapping, spanking, or hitting with any object.2. Cruel and unusual punishment.3. Assignment of excessive or inappropriate work.4. Denial of meals and daily needs.5. Verbal abuse, ridicule, or humiliation.6. Permitting a child to punish another child.7. Chemical or mechanical restraints.8. Seclusion or isolation.9. Denial of planned visits, telephone calls, or mail contact with birth family or casworker.

10. Threat of removal from home.

I have read this discipline policy of physical punishment and do comply with it.

If you are submitting this application electronically, checking this box indicates aggreement to the above.

Applicant Co-applicant

Printed Name of Applicant DateSignature

Printed Name of Applicant DateSignature



Monthly Family Income and ExpendituresThis information is needed to help give an understanding of how you manage your income as a part of the total picture of yourfamily life. Many of the items listed below may not be met on a monthly basis, and for them it may be convenient to calculate forthe yearly amount and divide by 12. Leave blank the items that do not apply to you. this form is to be completed by parents,prospective foster/adoptive parents, and relative caregivers.

Date of Birth

MM/DD/YYYY

Applicant


Sex SSN

XXX-XX-XXXX

Sex SSN

XXX-XX-XXXX

Date of Birth

MM/DD/YYYY

Co-Applicant


Names of others living in your home:

Phone Number


Address

Street Address


Postal / Zip Code

RESOURCES

Specify "Other" Other

$

Checking Account

$

Savings Account

$



EMPLOYMENT AND MONTHLY INCOME

Applicant Current Occupation Time in PositionEmployer

Time in PositionEmployerCo-Applicant Current Occupation

Combined Gross Income from Employment

$

Additional Income

$

Source of Additional Income

Total Combined Income

$

MONTHLY EXPENDITURES (continues on next page)

Home Mortgage Payment

$

Total Utilities

$ (Electric, Fuel, Water, Telephone, etc)

Rent

$

Homeowner/Renter's Insurance

$

Life Insurance

$

Medical Insurance

$

Food

$

Medical/Dental Expenses

$

Clothing

$

School Expenses

$

Church and Charity

$

Recreation

$



Installment Payments for:

ItemItemItem

Payment Amount

$

Payment Amount

$

Payment Amount

$

Other Expenses

ExpenseExpense Expense

Amount

$

Amount

$

Amount

$

Total Monthly Expenses

$

If you are submitting this application electronically, checking this box indicates a signature(s)


DatePrinted Name of Applicant Signature

DatePrinted Name of Co-Applicant Signature



Autobiography(ies)No one knows your life beter than you do. Tell us about it in your own style, covering the following topics. You may tape record or write it. Remember,what you write is more important than how you write it. These questions are just a guide, so don't worry about answering every question. Don't worryabout spelling, handwriting, or getting a "grade" - it's your life.

If you are filling this out on your computer, create a separate document answering these questions and email it to Apelah with your completed form.

YOUR FAMILY Describe the home or homes you lived in as you grew up. What were the members of you family like? What are somoneof your most important memories (good or bad)? What challenges did you family face?

FAMILY RELATIONSHIPS Describe your parents as a couple. What kind of relationship did they have as you were growing up? How did theyhandle money, disciipline of the children, sex education? In what ways would you hope to be like them as a parent? Whatthings would you do differently?

GROWING UP Who did you feel closes to as you were growing up? Was your family happier or less happy than most families? Why?What was school like for you? Describe friends and activities during your growing-up years. What were your biggestproblems in your teen years?

JOB HISTORY Please describe your job history, giving the reasons for leaving each job and what you liked and disliked about each job.What do you enjoy about your present job? What do you dislike about it? what hours do you work? Do you travel withyour job?

PERSONAL RELATIONSHIPS (answer as applicable) What attracted you to your spouse/partner? What problems have you and your spouse/partner had to overcome? Whatdo you and your spouse/partner disagree about most often? How do you make decisions? How are anger and affectionexpressed in your household? List anypast marriages, giving reasons for the break up. What contact do you have withprevious spouse(s)? If there was a previous marriage(s), described the curcumstances under which it ended and howyou coped with your feelings.

CHILDREN (answer as applicable) Describe the personality of each child living with you. Describe any children who do not live with you, including childrenfrom previous relationships. If you have no children, what have your experiences with children been? If you haveparenting experience, what have you enjoyed most and disliked most about parenting? What kinds of discipline do youfind to be the most effective? How do your children get along with each other? What do you expect from your children?

OVERVIEW What challenged have you faced, and how have you coped with them? Describe your pets. Please give the kind of pet,name, and age of the pet. What do you do for fun? Describe the activities that you attend away from home during atypical week? Describe your neighborhood and your relationship with your neighbors. What schools are children in yourneighborhood zoned to attend?

RESOURCE PARENT What influenced you to apply to become a resource parent at this time? Have you previously been a foster, adoptive, orkinship parent?

How many tapes/recordings?How many pages did you attach?



Verification of Applicant's Residence Over the Past Five Years

Name


Permanent Address

Street Address

City State / ProvinceHow long have you lived at your current address?

List below other addresses where you have lied in the last five (5) years. Give the phone number of the law enforcementoffice (sherff's office) serving that jurisdiction.

RESIDENCE PHONE NUMBER OF LAW ENFORCEMENT

1.

Street Address


Phone Number


Phone Number


2.

Street Address


3.

Street Address


Phone Number




We understand that as foster parents we cannot contract with, be employed by, or train with another agency(as a foster parent) as long at the foster parent is contracted with Meritan/Apelah. Foster parent, child, andcase documentation are private and confidential. Training records are the property of the agency and are nottransferrable.

We understand that we will be reading and/or hearing confidential information about individual(s) and theagency. I further understand that in my role I am obligated to keep all information that I learn private andconfidential. Private and confidential information belongs to Meritan and its affiliates. Knowledge of theinformation is solely for providing care. Any unethical or illegal disclosure, copying, distribution, or taking ofany action in reliance on the content of this information is prohibited under penalty subject to the limits of thelaw.

I hereby attest to the completeness and accuracy of the application, authorize verification and investigations,and fully indemnify against any liability the agency and responding sources to ensure the safest and mostappropriate placements for the population served. In addition, I

havehave not

Name


certify and affirm that to the bestof my knowlege and belief I

had or received a finding of substantiated case of abuse, neglect, or mistreatment or exploitation against me.As a condition of submitting this application and in order to verify this affirmation, I further release andauthorize Meritan, Inc. and its affiliates and the Federal, State, and Local Goverment and their agencies tohave full and complete access to any and all current or prior personnel, administrative, or investigativerecords, from any party, person, business or agency, as pertains to any allegations against of of abuse,neglect, or mistreatment and to consider this information as may be deemed appropriate.

SignaturePrinted Name of Applicant Date

DateSignaturePrinted Name of Co-Applicant

If submitting this application electronically, checking this box indicates a signature(s).


ONCE YOU HAVE COMPLETED THIS FORM AND ANY ATTACHED DOCUMENTS, PLEASESAVE IT FOR YOUR OWN RECORDS AND EMAIL IT TO:

[email protected]



Foster Parent Application - Apelah

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