Free 10100.FH11 - Indiana

APPLICATION FOR FOSTER FAMILY HOME LICENSE
State Form 10100 (R10 / 6-06) / CW 0317 DEPARTMENT OF CHILD SERVICES

Foster Family Home License Therapeutic Special Needs Regular

County CENTRAL / LOCAL OFFICE USE ONLY Enter resource ID number assigned by the Indiana Child Welfare Information System (ICWIS). If the number is less than 9 digits, use zeros for first spaces.

INSTRUCTIONS: Include the full name of all persons living in your home at present. For further entries, use the reverse side of this form. FULL NAME Applicant A Applicant B Children DATE OF BIRTH SOCIAL SECURITY NUMBER PLACE OF BIRTH RELATION TO FAMILY

OCCUPATION OR SCHOOL GRADE

NAME OF EMPLOYER

Others

Present address (number and street, city, state, and ZIP code) Directions to home

T elephone number (home)

(

)

T elephone number (office)

(

)

Number of children for whom you want to provide care.

Age and sex

Please indicate the special needs characteristics of the children for whom you would consider providing care.

What led you to apply for a foster family home license?

None Child 2 years of age or older Medical / physical challenge Mental / emotional challenge

Behavior challenge Adolescent Educational challenge

T.V. Radio Internet Newspaper Billboard / poster Family / friends

Licensed child placing agency / list State-sponsored recruitment activities Faith-based organization Other (specify)

Member of sibling group of 2 or more children, at least 1 of whom is 2 years of age or older and will be placed with the sibling group in the same home. Reasons for wanting to care for children in need of services:

Have you ever applied for a foster family home license ? Yes No Have you ever cared for / fostered a non-related child? Yes No How many children do you have of your own? Applicant A _______________ Applicant B _______________ Place of marriage

If Yes, from whom? If Yes, please explain: Family income per month Religion Applicant A _______________ Applicant B _______________ Do you have a yard? Yes Continued on reverse side No Race Applicant A _______________ Applicant B _______________

$

Date of marriage (month, day, year) Number of rooms in your home

Please give, as references, the names of your physician and four persons (non-relatives) who know your family life.
NAME Name of physician STREET ADDRESS CITY STATE, ZIP CODE , TELEPHONE NUMBER

( ( ( ( (
Other states in which applicant has resided: Maiden or married names / aliases used: Applicant A Applicant B

) ) ) ) )

If applicant has been named in any CPS reports as having committed any act of child abuse / neglect as determined by the Department of Child Services, this may be grounds for revocation or denial of a license.
Has applicant been named in any substantiated or indicated cases of child abuse and neglect as determined by Child Protection Services in Indiana or in any other state? If yes, what state(s)? No Yes If yes, what year? If yes, what county(ies)? Please provide details.

I certify that all statements made in this application, and any attachments thereto, are correct to the best of my knowledge.
Signature of applicant A Date signed (month, day, year) Signature of applicant B Date signed (month, day, year)

Use for additional entries from front page, if required