APPLICATION FOR FOSTER Family CARE LICENSE

Initial Application	Renewal Application

For your initial application all sections MUST be completed. At renewal you will be required to complete the Identifying Information and then indicate and complete any section where the information has changed.

I/We are interested in:	Foster Care	Foster to Adopt

IDENTIFYING INFORMATION (Complete for initial and renewal application)
Family Last Name:	Family Home Phone:
Current Physical Address:
Town/City:	State:	NH	Zip Code:
Mailing Address (if different):

SPECIFIC INTEREST (Complete at renewal if changes) CHANGES INDICATED
WILLING TO CARE FOR:
Number of Children:	Age:	To	Male Female Both
Interested in adopting? Yes No Unsure

HISTORY AS A FOSTER CARE OR ADOPTIVE FAMILY (Initial Application only)
Have you applied to this or any other agency/state for foster care, relative care or adoption?	Yes No
If “Yes” please list the agency name(s), state(s), estimated date(s) of application, and if you were approved.
Agency Name	State	Estimated Date of Application	Approved
Yes No
Yes No

HEAD OF HOUSEHOLD #1	HEAD OF HOUSEHOLD #2
Full Name:
Other Names:
Social Security #:	XXX - XX -	XXX - XX -
Date of Birth:
Place of Birth:
Gender:	Male Female	Other:	Male Female	Other:
Race (check all that apply):	White	Asian	White	Asian
Black or African American	Black or African American
Native Hawaiian/Other Pacific Islander	Native Hawaiian/Other Pacific Islander
Alaskan Native or Native American	Alaskan Native or Native American
Tribe:	Tribe:

HEAD OF HOUSEHOLD #1	HEAD OF HOUSEHOLD #2
check at renewal if changes indicated.	check at renewal if changes indicated.
Ethnic Background:	Hispanic or Latino Other:	Hispanic or Latino Other:
Email Address:
Landline (if applicable):
Cell Number:
Additional Phone:
Primary Language:	Speak	Read	Write	Speak	Read	Write
Other Language(s):	Speak	Read	Write	Speak	Read	Write
Current Address
From To Current	From To Current
Prior Address (For the past 5 years)
From To	From To
Prior Address:
From To	From To
Prior Address:
From To	From To

ADDITIONAL HOUSEHOLD MEMBER INFORMATION (Complete at renewal if changes) CHANGES INDICATED
Please provide the following information for ALL additional individuals living in your home, full-time or part-time, including their children. Attach additional paper if needed.
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years

ADDITIONAL HOUSEHOLD MEMBER INFORMATION Continued
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years
Name:	Gender: Male Female Other
Date of Birth:	Age:	Relationship:
Phone Number:	Cell Home Work	Email:
Student:	Yes No	Grade:	Occupation:
Lived at this address for the past 5 years? Yes No, If “No” list all addresses for the past five years

MARITAL/DOMESTIC PARTNER RELATIONSHIPS (Complete at renewal if changes) CHANGES INDICATED
Current Status:	Married Single Divorced Widowed Civil Union
Date of Current Marital/Domestic Partner Relationship:
Place of Marriage:

PAST MARRIAGE(S)/DOMESTIC PARTNER RELATIONSHIP(S)	Check if additional sheets attached
CHANGES INDICATED
HEAD OF HOUSEHOLD #1	date begun	date ended	death	divorce	other
Name of Past Spouse/Partner
Name of Past Spouse/Partner
Name of Past Spouse/Partner

PAST MARRIAGE(S)/DOMESTIC PARTNER RELATIONSHIP(S)*	Check if additional sheets attached
CHANGES INDICATED
HEAD OF HOUSEHOLD #2	date begun	date ended	death	divorce	other
Name of Past Spouse/Partner
Name of Past Spouse/Partner
Name of Past Spouse/Partner

MILITARY SERVICE	CHANGES INDICATED AT RENEWAL	CHANGES INDICATED AT RENEWAL
HEAD OF HOUSEHOLD #1	HEAD OF HOUSEHOLD #2
Served/Currently Serving:	Yes No N/A	Yes No N/A
Branch of Military:
Dates of Service:	To	To
Type of Discharge:
Served/Currently Active in the Reserves:	Yes No N/A	Yes No N/A
Reserves Dates:	To	To

CURRENT EMPLOYMENT (Complete at renewal if changes) CHANGES INDICATED
HEAD OF HOUSEHOLD #1	HEAD OF HOUSEHOLD #2
Employment Status:	Employed Unemployed Not in work force (retired, disabled, etc.)	Employed Unemployed Not in work force (retired, disabled, etc.)
Employer:
Job Title/Occupation:
Work Phone:

EDUCATION (Complete at renewal if changes)) CHANGES INDICATED
HEAD OF HOUSEHOLD #1	HEAD OF HOUSEHOLD #2
Last Grade Completed:
Year of High School Graduation or GED:
Post-Secondary Education:	Yes No Diploma Received: Yes No Date of Graduation:	Yes No Diploma Received: Yes No Date of Graduation:

ADULT CHILDREN ( Not Applicable)	Check if additional sheets attached
CHANGES INDICATED
Please provide the following information for your adult child(ren), if applicable. Attach additional paper if needed.
Name:	Age:	Child of: #1 #2 Both
Address:
City:	State:	Zip Code:
Phone Number:	Email:
Name:	Age:	Child of: #1 #2 Both
Address:
City:	State:	Zip Code:
Phone Number:	Email:
Name:	Age:	Child of: #1 #2 Both
Address:
City:	State:	Zip Code:
Phone Number:	Email:
Name:	Age:	Child of: #1 #2 Both
Address:
City:	State:	Zip Code:
Phone Number:	Email:

EMERGENCY/DISASTER PLANNING INFORMATION (Complete at renewal if changes)	CHANGES INDICATED
In the event of an emergency, would you be willing to care for additional children, short-term? Yes No
In the event of an emergency, where would you go? Include information on In-State and Out-of-State locations.
IN STATE:
Name:	Phone Number:
Relationship:	Alternate Number:
Street Address:
City/Town:	Zip Code:

OUT OF STATE:
Name:	Phone Number:
Relationship:	Alternate Number:
Street Address:
City/Town:	State:	Zip Code:

Authorization/Statement of Understanding:

I/We have reviewed the Administrative Rule He-C 6446 and will adhere to the rules if I/we are licensed as a Foster Family Care provider. I/We authorize the NH Division for Children, Youth and Families (DCYF) to receive the results of the central registry check, the state registry check, and the out-of-state child abuse and neglect registry checks.

I/We understand that:

The Division for Children, Youth and Families examines its child abuse records and the criminal conviction records of the State Police on Adoptive/Foster Parent applicants (RSA 170-E:4, III), or may revoke, or refuse the license of any provider who furnishes, or makes any misleading, or false statement, or report to the Division (RSA 170-E: 1, IV);

All household member 18 years and older shall be subject to a criminal records search through the NH state and local police, and through all other states in which the individual has resided for the preceding 5 years;

All household members 18 years old or older shall be subject to a Federal Bureau of Investigation fingerprint record check;

Information shared about a foster child’s safety, the caregiver’s safety and the appropriateness of the placement, is confidential (RSA 170-E: 9,I (a) (13));

Other information about the child’s family, or the circumstances of his, or her placement, must also be kept confidential. This information was taken from DCYF case records and files whose confidentiality is protected by federal law. Federal regulations (42 CFR, Part 2) prohibit the further sharing of this information without obtaining the written consent of the individual to whom it pertains, or as otherwise permitted by federal regulations;

Completion of this application does not constitute acceptance into the foster care family program*. It is a statement of intention only and may be withdrawn at any time; and

DCYF has the right to verify information contained in this application.

I/We understand the above statements and verify that all statements made are true.

Head of Household #1	Date
Head of Household #2	Date

* In addition to the application packet (listed below) all candidates will undergo a homestudy evaluation which will include, but is not limited to the following:
Medical/Mental Health History; Financial Information; Insurance/Safety Verification;	References; Personal and Family History; and Initial Training.

a completed application packet contains:
Completed “Application For Foster Family Care License”;
Completed “Fire Department Inspection” submitted by fire inspector;
Completed “Foster and Adoptive Family Home Health Inspection Report” submitted by the local health officer;
Results of state criminal history records search for all applicants and all household members 18 years of age or older, submitted by the NH Division of State Police;
Results of local police clearance checks for all applicants and all household members 18 years of age or older, as reported by local police departments;
Results of Federal Bureau of Investigations fingerprint record check for all applicants and all household members 18 years of age or older, submitted by the NH Division of State Police; and
Results of State Central Registry check for all applicants and all household members 18 years of age or older, submitted by DCYF.
For applicants and household members 18 years of age or older who have lived outside the State of New Hampshire within the past 5 years of application:
Results of state criminal history records search for each state resided in; and
Results of the child abuse and neglect registries for each state resided in.

RENEWAL APPLICATION
A Foster Family Care License is only valid for up to two years. A renewal will include, but is not limited to an updated application packet (see below) and updated:
Medical/Mental Health History; Financial Information; Insurance/Safety Verification;	Training Documentation; and Updated Home Study.

a completed renewal packet contains:
Updated “Application For Foster Family Care License”;
Completed “Fire Department Inspection” submitted by fire inspector;
Results of state criminal history records search for all applicants and all household members 18 years of age or older, submitted by the NH Division of State Police;
Results of local police clearance checks for all applicants and all household members 18 years of age or older, as reported by local police departments;
Results of Federal Bureau of Investigations fingerprint record check for all applicants and all household members 18 years of age or older, submitted by the NH Division of State Police; and
Results of State Central Registry check for all applicants and all household members 18 years of age or older, submitted by DCYF.
For applicants and household members 18 years of age or older who have lived outside the State of New Hampshire within the past 5 years of application:
Results of state criminal history records search for each state resided in; and
Results of the child abuse and neglect registries for each state resided in.

RENEWAL SIGNATURES

I/We verify that all statements made are true.

Head of Household #1	Date
Head of Household #2	Date

Other Names - means nicknames, aliases, prior married names, maiden name etc.

“Household members” means all individuals who reside in the foster family home or might reside there during any time that there is a child in care.