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FOSTER CARE RESOURCE INQUIRY FORM

Applicant #1 Information:
Surname:
First and Middle Name:
Maiden Name:
Previous Married Name:
Alias/ Known As:	Marital Status:
Date of Birth:	Gender:
Relationship (e.g.mother, father, grandparent):
Country of Birth:	Ethnic Details:
Citizenship:	Native Band Name and No:
Language (primary):	Language (other):

Religion:	Education Completed:	Occupation/ Place of Employment:
Income Source:		Home Address:
Years/ Months at Current Address:		Previous Area of Residence:
Home Phone:	Work Phone:	Cell Phone/ Pager:
Email Address:

Applicant #2 Information:
Surname:		First and Middle Name:
Maiden Name:		Previous Married Name:
Alias/ Known As:	Marital Status:	Relationship (e.g.mother, father, grandparent):
Gender:	Date of Birth:	Country of Birth:
Ethnic Details:	Citizenship:	Native Band Name and No:
Language (primary):	Language (other):	Religion:
Education Completed:		Occupation/ Place of Employment:
Income Source:		Home Address:
Years/ Months at Current Address:		Previous Area of Residence:
Home Phone:	Work Phone:	Cell Phone/ Pager:
Email Address:


Children Information:
Children	Child "A"	Child "B"	Child "C"
Surname:
First and Middle Name:
A.K.A:
Date of Birth:
Gender:
Legal Guardian:
School/ Grade:
Country of Birth:
Language:
Residing in the Home?	Yes No	Yes No	Yes No

Other Adults Living in the Home:	1	2	3
Surname:
First and Middle Name:
Gender:
Date of Birth:
Relationship to Applicant:
Criminal Offences:
Any Previous CAS Contact:
Will They be in Contact with Foster Child?	Yes No	Yes No	Yes No


Details of Referral
How did you find out about fostering?
Agency Website	Homes for Kids	Newspaper	Foster Parent Referral
Any Other E1R1 Referral	Fostering Contact	Re-application	Other
What motivated you to inquire?
Why do you feel the timing is right?
Other Details (family composition; work flexibility; child care plan; special skills):


Type of Child You May Consider Fostering
Age:		Gender:	Male Female Both
Beds Available:		Race/ Ethnicity:	Open Limited
Language:	Open Limited	Religion:	Open Limited
Siblings:	Open Limited How many?
Special Needs:	Open Limited Specify:
Natural Family Contact:	Open Limited
Restrictions:


Previous Foster Care Application
Have you previously applied for fostering or adoption? Yes No
Have you started or completed a foster care/ adoption education program/ PRIDE? Yes No
Have you started or completed a foster care, adoption or private adoption homestudy assessment? Yes No

Physical Environment
Do you have a spare bedroom (with adequate space) on the same floor (not in the basement)? Children over the age of six (6) cannot share a bedroom with a child of the opposite sex. Bedroom must have a window.	Yes No N/A
Do you have one million dollars ($1,000,000) liability insurance on your home and vehicles?	Yes No N/A
Do you have access to a vehicle to transport foster children to access visits, doctor? therapist, school meetings etc.?	Yes No N/A
Do you have pets?	Yes No N/A
If applicable, are pool/ponds/hot tubs safe/fenced for children?	Yes No N/A
Your Family
Are there individuals other than the applicants living in the home? They will need to be part of the foster home study (interview, police check) as they will be in contact with the foster child.	Yes No N/A
Do you feel that you can provide a safe, supportive and secure living environment for children?	Yes No N/A
Have you been in an established relationship for at least two (2) years?	Yes No N/A
Have there been any major traumas or stressors in your life within the last year or two (2)? (Example: job changes, moving, health, births/deaths in the family)	Yes No N/A
Do you have a stable family income?	Yes No N/A
Is your family supportive of your wish to foster?	Yes No N/A
Are you pregnant now, or have children under one (1) year old?	Yes No N/A
Are the caregivers in your home in good health?	Yes No N/A
Are the caregivers taking any medication? if yes, who for what and what type of medication?	Yes No N/A
Is there a caregiver available to care for children not in school?	Yes No N/A
Has a person in your home ever been involved with this or any other CAS?	Yes No N/A
Can we get your verbal consent to do an internal Database check? (Written consent to share information will be secured at home study visit.)	Yes No N/A
Do any of the persons in your home have a criminal record?	Yes No N/A
Has a person in your home ever been charged with a criminal offence?	Yes No N/A
Do you have experience working with children? (Work, sports, etc.)	Yes No N/A
Do you or any other person in your home smoke?	Yes No N/A
Agency
Are you prepared to work as part of the team?	Yes No N/A
Are you prepared to work with the family of the child in care so that the child has continued contact with the family?	Yes No N/A
The Child and Family Services Act, which governs our agency, stipulates that foster parents cannot use corporal punishment. Can you say that you will follow this and do not spank or hit children?	Yes No N/A
Becoming Foster Parents
Are you prepared to attend PRIDE training prior to approval and placement of a foster child?	Yes No N/A
Will you be able to provide references for your application?	Yes No N/A
Are you considering applying for adoption as well?	Yes No N/A