Foster Application Form – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

1. APPLICANT(S) First	Middle	Last Name

		5a. PREVIOUSLY LICENSED,	DATE(S):	5b. PREVIOUS DENIAL, EXCLUSION, REVOCATION,			DATE(S):
		CERTIFIED OR APPROVED:
2.	APPLICANT(S) AGE			ADMINISTRATIVE ACTION OR
		■ Yes ■ No				■ Yes ■ No
	Over 18 Years Old			DECERTIFICATION
		TYPE LICENSE(S):		LICENSING AGENCY(IES):
	■ Yes ■ No
3.	TYPE APPLICATION
		ADDRESS(ES) OF PREVIOUS LICENSE(S):	CITY	STATE	ZIP	LICENSE NUMBER(S)

■New Application

■Modification

	■ Location Change	6a.	RESIDENCE/ ADDRESS		CITY	STATE	ZIP		6b. CHECK ONE:
									■ Own ■ Rent ■ Lease
4.	TOTAL CAPACITY
		7.	MAJOR CROSS STREETS			8a. DAYS & HOURS APPLICANT(S) CAN BE			8b, HOME PHONE:
	REQUESTED_________
						REACHED:			8c.	DAYTIME PHONE:
9a.	BODY OF WATER:	9b. PROVIDE DESCRIPTION OF BODY OF WATER:							10.	WEAPONS IN HOME:
	■ Yes ■ No								■ Yes ■ No
11.	ADULTS IN THE HOME (Ages 18 and over)
	First Name		Middle			Last Name		D.O.B.		Relationship to You

12. CURRENT CHILDREN IN YOUR HOME (DO NOT LIST NAMES)

13. PREFERRED AGE AND SEX OF CHILDREN:			PREFERRED TYPE OF CHILDREN:
Ages 0 months to 2 years	_____ (Male)	_____ (Female)	■ _____ Non-Ambulatory
Ages 2 years to 9 years	_____ (Male)	_____ (Female)	■ _____ Ambulatory
Ages 10 years to 17 years	_____ (Male)	_____ (Female)	■ _____ Special Health Needs

14.APPLICANT DECLARATION - I/We declare that: (please initial)

A.I/We have money to maintain the level of service required in a Foster Family Home by Law. ______ ______(initials) (H&SC 1520(c))

B.I/We shall seek an approved fire clearance if accepting nonambulatory children. ______ ______ (initials) (Section 89420)

C.I/We have read and understand the regulations and shall comply with the laws and regulations governing standards for a Foster Family Home. ______ ______ (initials) (Section 89318)

D.I/We shall file a modified application before requesting changes in our license or changing location. _____ ______ (initials) (Section 89234)

E.I/We shall notify the licensing agency when we want to discontinue our license. _____ ______ (initials) (Section 89235)

F.I/We have received, read, and understand the Children’s Personal Rights. _____ ______ (initials) (Section 89372)

G.I/We will maintain adequate safeguards and accurate records of all cash resources belonging to the child (children) entrusted to

the home, in accordance with regulations of the California Department of Social Services. ______ ______ (initials) (Section 89226)

H.I/We have control of the residence listed in Section #6a. _____ ______ (initials) (H&SC 1502(a)(5))

15.PERJURY STATEMENT - I/We declare under penalty of perjury that the statements on this application and accompanying attachments are correct to the best of my/our knowledge.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

INSTRUCTIONS FOR FOSTER FAMILY HOME APPLICATION

This is the application form for a Foster Family Home license. The numbers on this page are the same as on the

front. Information on this form is public information.

1.APPLICANT(S) - The applicants are the persons who will be responsible for providing care in their own home. All the applicants must live in the home to be licensed.

2.APPLICANT(S) AGE - A person must be at least 18 years of age or older to be licensed for care. A "Yes" check means all the applicants are 18 years of age or older.

3.TYPE APPLICATION - A New Application is a request to license both an individual and a home that are not now licensed. A Modification is a change to the existing license, such as a change in capacity, structure, changes of term and conditions and types of children. A Location Change is a request by a licensee to change their license to a home in another location.

4.TOTAL CAPACITY REQUESTED - Please provide the number of children you plan to serve (no more than 6 children).

5a. PREVIOUSLY LICENSED, CERTIFIED OR APPROVED - All prior or pending licenses, approvals, certifications, or vendor approvals must be explained on a separate sheet and submitted with your application.

5b. PREVIOUS DENIAL, EXCLUSION, REVOCATION, ADMINISTRATIVE ACTION OR DECERTIFICATION - All prior or pending licensure revocations, denials, exclusions, decertifications or revoked vendor certifications must be explained on a separate sheet and submitted with your application.

6a. RESIDENCE/ADDRESS - Your residence/address is the location of the home in which you live and want to provide care. This is the residence/address that the licensing agency will review to determine whether care can be provided in the home.

6b. CHECK ONE - Check whether you own, rent or lease your place of residence.

7.MAJOR CROSS STREETS - The cross streets to your home are helpful to the licensing agency in finding your home. If your home is difficult to find, please also attach a sketch or map with landmarks or major cross streets.

8a. DAYS & HOURS APPLICANT(S) CAN BE REACHED - Provide the days and hours you can be reached in case of an emergency.

8b. HOME PHONE - Provide your home telephone number.

8c. DAYTIME PHONE - Provide a telephone number where you can be reached during the days and hours provided in 8a.

9a. BODY OF WATER - You must inform your licensing office if there is a body of water located on the property. Some important examples would be: swimming pool, fish pond, fountain, private well, etc.

9b. PROVIDE DESCRIPTION - Please provide a description of the body of water. Include location and size.

10.WEAPONS IN HOME - You must inform your licensing office if there are firearms or other dangerous weapons in the home.

11.ADULTS IN THE HOME - List all adults who live in your home including yourself, family members, boarders or other relatives. Do not list your own children under 18, guardianship or foster children. If you do not have enough space attach additional paper.

12.CURRENT CHILDREN IN YOUR HOME – List only the relationship, date of birth and sex of all children you are currently caring for. Do not list the names of children on this form.

13.PREFERRED AGE AND SEX OF CHILDREN & PREFERRED TYPE OF CHILDREN - By completing each section you are simply providing your placement worker with an idea of the type of children you are interested in caring for within each age group and each category. Please note this section is informational only.

14.APPLICANT DECLARATION - You need to declare to the licensing agency that you have enough money to maintain your home, you have basic fire protection, you will comply with licensing laws and regulations and you will notify the licensing agency whenever you plan to change your license. The presence of situations that may pose a danger must be reported to the licensing agency. Some important examples that you must report are: pools, guns and animals. Review and declare compliance by initialing each of the caregiver’s responsibilities listed.

15.PERJURY STATEMENT - Each applicant must sign the application. The signatures should be the same as the names listed on the top of the form. The signature is signed under a perjury oath.

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