FOSTER CARE TO ADOPT PRE-SCREENING TOOL

Please fill out the following form in order to participate in our activity.

First name:

Last name:

Date:

Month

Day

Year

Spouse's Full Name:

Phone Number:

Address:

County Reside In:

Email Address:

Number of children in the home, ages, sex:

Name/Age:

Date of Birth:

Social Security #:

Name/Age:

Date of Birth:

Social Security #:

Name/Age:

Date of Birth:

Social Security #:

How did you hear about us?

Friends

Social Media

Other

Marital Status:

Have you ever been a foster parent?

Yes

No

Have you ever adopted before?

Yes

No

If a CPS transfer family:

Name of CPS worker (whom we can contact for information, such as training certificates, CPR/First Aid Certification, Physical, TB Skin test and home study):

Short answer

CPS Worker's Phone Number (If you have it):

Name of person completing pre-screen tool:

I declare that the information I've provided is accurate and complete.