I Identifying informations


Applicant 1
Last Name
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First Name
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Middle Name
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Date of Birth
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Gender
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Home Address
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City
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State
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Zip Code
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Country
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Home Phone Number
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-
Work Phone Number
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Race/Ethnicity
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Marital Status
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Primary Income
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Level of Education
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Occupation
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Driver License No.
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Monthly Income
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Monthly Expenses
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Social Security Number
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Employer’s Name – Employed for how long?
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Other Income
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Place of Current Marriage:
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Previous Marriage
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Place of Previous Marriage:
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Terminated By:
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Applicant 2
Last Name
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First Name
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Middle Name
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Date of Birth
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Gender
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Home Address
Invalid Input
City
Invalid Input
State
Invalid Input
Zip Code
Invalid Input
Country
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Home Phone Number
-
-
Work Phone Number
-
-
Race/Ethnicity
Invalid Input
Marital Status
Invalid Input
Primary Income
Invalid Input
Level of Education
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Occupation
Invalid Input
Driver License No.
Invalid Input
Monthly Income
Invalid Input
Monthly Expenses
Invalid Input
Social Security Number
Invalid Input
Employer’s Name – Employed for how long?
Invalid Input

Other Income
Invalid Input

Place of Current Marriage:
Invalid Input
Invalid Input
Previous Marriage
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Place of Previous Marriage:
Invalid Input
Invalid Input
Terminated By:
Invalid Input
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II Criminal History


Applicant 2
a) Have you ever been arrested for an offense other than a minor traffic violation?
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b) Have you ever been convicted of a crime in California?
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c) Have you ever been convicted of a crime in another state, federal court, military or a jurisdiction outside the U.S.?
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d) Have you ever been reported to Children’s Protective Services or Law Enforcement for alleged child abuse, neglect or abandonment?
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e) Did you reside in another state within the last 5 years
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If “yes,” which State ?:
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Applicant 1
a) Have you ever been arrested for an offense other than a minor traffic violation?
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b) Have you ever been convicted of a crime in California?
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c) Have you ever been convicted of a crime in another state, federal court, military or a jurisdiction outside the U.S.?
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d) Have you ever been reported to Children’s Protective Services or Law Enforcement for alleged child abuse, neglect or abandonment?
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e) Did you reside in another state within the last 5 years
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If “yes,” which State ?:
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III Parrent/Child Relationship


Minor Children of Applicant(s)
Full Name DOB(yyyy-mm--dd) Gender Relationship(Indicate if addopted or legal guardian) Lives at Home Do you financially support child Address
More Adult Children of Applicant(s)
Full Name DOB(yyyy-mm--dd) Gender Relationship(Indicate if addopted or legal guardian) Lives at Home Do you financially support child Address
More

IV Other people living in the home (adult and/or minor)


Full Name DOB(yyyy-mm--dd) Address
More

V Historical Reference Check


a) Do you currently have child care license?
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If “yes,” When does it expire?:
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Capacity:
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If “yes,” Is child care center active?:
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# of children:
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b) Have you ever had your child care license placed on HOLD
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If “yes,” Explain?
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c) Have you or any adult living in your household ever been certified, had a relative placement, decertified or put on a placement HOLD by any Foster Family Agency or by DCFS?
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if “yes,” please list name of agency(ies), phone #, & reasons
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d) Have you ever been denied a child care license, or to provide foster care services from the State of California, Community Care Licensing or any Foster Family Agency?
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If “yes,” Why?
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V Child Desired


a) Please describe the characteristics such as age and gender:
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Would you accept a sibling group?
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If so, how many?:
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VII Personal References


Please list the name and address of three individuals, at least two must be unrelated to you, who have knowledge of your home environment, lifestyle and capability to be a resource/adoptive parent
Full Name Telephone number(yyyy-mm--dd) Mailing Address
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VIII Transportation


a) Do you own a car?:
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Type:
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Year:
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b) Number of traffic citations in past 5 years: Applicant 1:
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Applicant 2:
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c) Insurance Company:
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   Type of Coverage:
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d) Do you have a car available at all times?:
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   If not, what alternative transportation plans do you have?:
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Who will care for children in your absence or in case of an emergency?:
   Relationship:
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   Name:
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   Address:
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   Phone:
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-
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IX Health


a) Do you or any members of the family have any serious health problems?
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b) Psychological problems?
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c) Physical problems?
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If yes to any, please explain:
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Are you or any member of the family taking any health medication?
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Are you or any member of the family taking any mental health medication?
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Any other medication?
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If yes to any, please explain:
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X Buildings and grounds


a) Do you keep firearms in your home?
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If yes, is it registed
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Please list current sleeping arrangements in your home
Bedrooms Size Beds Occupants
First bedroom x
Second bedroom x
Third bedroom x
Fourth bedroom x
c) Are any of these bedrooms built without a city permit?
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PLEASE READ CAREFULLY BEFORE SIGNING
I/We affirm that the information provided on this form is true and correct to the best of my/our knowledge.

  • • In signing this application, I/we understand that the completion of routine forms will be required of my/our references, physician and employer and that my/our financial and marital status will be verified and a criminal background check will be conducted. I/we have been advised of my/our duty of honest disclosure along with the ongoing duty of disclosure of new events or information which may require and updated or amended home study.
  • • Section 1506.8 of the Health and Safety Code requires that all Foster Family Agencies contact any county or state offices that have licensed any applicant to operate a Foster Family Home, or any Foster Family Agency that has certified an applicant as a foster family.
  • • By signing this application you are hereby authorizing Nuevo Amanecer Latino Children’s Services to conduct a reference check based upon information provided by you.
  • • By signing this application you are declaring that the information provided on this form is true and correct.
  • • Anyone knowingly submitting material information that is false pursuant to section 1506.7, 1506.8 and 1506.9 H&S is guilty of a misdemeanor. Applicant(s) understand that in the event that false information is provided, Nuevo Amanecer Latino Children’s Services reserves the right to terminate the certification process of the prospective foster family.

PLEASE NOTE: anyone 18 years of age or older who will come in regular prolonged contact with the foster children (adults or adult children in the home, babysitters, transport person, etc.) MUST submit physical exam, TB-test, fingerprints and Child Abuse Index Clearance form to this office PRIOR to any prolonged contact with the children.