Cfs 597A Form PDF Details

The journey to becoming a licensed foster family in Illinois is encapsulated within the CFS 597A form, a crucial document designed by the Department of Children and Family Services. Amended in May 2008, this form serves as the initial step for individuals or couples aspiring to provide a nurturing environment for children in need. Applicants are required to fill it out in duplicate, keeping one copy for their records—underscored by the directive to not make entries in agency-use only spaces, highlighting the structured protocol followed by the agency. The form requests detailed personal information including names, addresses, social security or ITIN numbers, as well as questions designed to assess the applicant's background and suitability for fostering—such as prior convictions, existing child care licenses, applications for child care licenses, and involvement with child welfare services. Additionally, it inquires about the applicant's ability to communicate in languages other than English, indicating the department's commitment to matching foster children with families capable of accommodating diverse linguistic needs. The assertion that operating a child care facility without a license constitutes a Class A misdemeanor emphasizes the seriousness with which this application process is treated. Moreover, applicants are required to declare their acquaintance with and agreement to adhere to the standards for which the license is sought, indicating a collaborative effort towards maintaining high standards in child care. The form concludes with an affirmation of truthfulness in the information provided, underscoring the legal and ethical obligations of prospective foster families. It not only acts as a gateway to fostering but also as a testament to the state’s dedication to child welfare, safety, and the promotion of equitable opportunities in foster care services.

QuestionAnswer
Form NameCfs 597A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois 597a form, dcfs form 597 c licensing monitoring record, cfs 597 home, cfs 597 a

Form Preview Example

CFS 597 A

State of Illinois

 

Rev. 5/2008

Department of Children and Family Services

Complete in duplicate.

 

APPLICATION FOR AN INITIAL FOSTER FAMILY HOME LICENSE

Retain one copy for your file.

 

 

DO NOT WRITE IN THIS SPACE – AGENCY USE ONLY

 

Region/Site/Field

6B-02-0I County No. 105

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Responsible for License

 

 

Date Received

 

 

 

 

 

 

Date Entered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supervising Agency No.

 

123797

 

 

 

 

 

Name

 

Family Resource Center

 

 

 

 

 

 

 

 

 

 

 

 

x Licensed Child Welfare Agency

Street Address

 

5828 North Clark Street

 

 

 

 

 

 

For DCFS Use Only

 

 

 

 

 

 

City

Chicago

 

 

 

 

 

 

 

Zip 60660

 

 

 

 

 

 

 

Independent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

 

Licensed Day Care Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No. (773) 334-2300

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Licensed Exempt Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE READ THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING THIS APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF APPLICANTS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ - __ __ - __ __ __ __

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

 

 

 

 

Middle

 

 

 

 

 

 

Social Security or ITIN No..

 

 

 

 

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__ - __ __ - __ __ __ __

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

First Name

 

 

 

 

Middle

 

 

 

 

 

 

Social Security or ITIN No..

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. and Street

 

City, State and Zip

 

 

 

 

 

 

 

 

County

 

 

 

 

Mailing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. and Street

 

City, State and Zip

 

 

 

 

 

 

 

 

County

 

 

 

 

Home

 

 

 

 

 

 

 

 

 

 

Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

Number

 

 

 

 

 

 

 

 

Area Code

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALL APPLICANTS PLEASE ANSWER THE QUESTION BELOW AND SIGN THE APPLICATION

 

 

 

 

 

 

1. Have you ever been convicted for other than a minor traffic violation?

 

No

 

 

Yes

 

 

 

 

 

 

 

 

If yes, explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Are you currently licensed for child care in Illinois?

 

No

Yes

License No(s).

 

 

 

 

 

 

 

 

If yes, give type of license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name on license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address on license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Have you ever been licensed for child care outside Illinois? No

Yes

License No(s).

 

 

 

 

 

 

 

 

If yes, give type of license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name on license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address on license(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.If you are not currently licensed for child care, complete the question below:

Have you ever applied for a child care license?

 

No

 

Yes

 

 

Was license issued?

No

Yes

 

 

 

 

 

 

Name on license

 

 

 

 

 

 

 

 

 

 

Address on license

 

 

 

 

 

 

 

 

 

 

5. Have you ever received child welfare services from the Department?

 

No

Yes

If yes, what was the reason for the service:

 

 

 

 

 

 

 

6. Does Applicant A and/or B speak a language other than English?

No

 

Yes If yes indicate:

Applicant A’s Language:

 

 

 

 

 

 

 

 

 

Applicant A’s Proficiency: Bilingual

 

 

Fluent

 

 

Conversational

Applicant B’s Language:

 

 

 

 

 

 

 

 

 

Applicant B’s Proficiency: Bilingual

 

 

Fluent

 

 

 

Conversational

 

I(WE), the undersigned, representing the facility herein named, hereby apply for license to operate a child care facility under the Child Care Act of 1969 as amended. I(WE) declare that, I(WE):

I.Have received a copy of the standards, have read and are familiar with the standards for which license is sought.

II.Will be subject to investigation upon application in regard to meeting standards.

III.Will cooperate with the licensing agency through the study.

IV.

Are aware that to operate a child care facility without a license or permit constitutes a Class A misdemeanor and that I(WE) may be

 

prosecuted for such misconduct.

V.Will be subject to supervision in terms of conformance with minimum standards upon issuance of a license.

VI.

Affirm that the information provided above is true. I(WE) understand that making materially false statements in order to obtain a

 

license or permit constitutes a Class A misdemeanor and that I(WE) may be prosecuted for such misconduct.

SIGNATURE(S)

DATE

DATE

INSTRUCTIONS FOR THE APPLICATION FOR AN INITIAL FOSTER FAMILY HOME LICENSE

Name of Applicant(s)

Enter the name(s) of the person(s) who are applying to be licensed as foster parent(s). Enter the social security or individual taxpayer identification (ITIN) number of each person listed in the spaces provided. If applicant is married and living with spouse, enter name and social security number for both persons.

Address

Enter the complete address of the home’s actual location.

Mailing Address

Use ONLY when the mailing address is different from the actual location of the home.

Telephone Number

Enter the area code and phone number of the home and work telephone if applicable.

All applicants should answer the questions on the bottom of the form.

If there is one applicant, he/she must sign the form. If there are joint/married applicants, both must sign.

DCFS is an equal opportunity employer, and prohibits unlawful discrimination in all of its programs and/or services.

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