Foster Care Application

Applicant A:

	Name:
	Date of Birth:
	Race:
	Home Phone:
	Work Phone:
	Occupation:

Applicant B:

Name:

Date of Birth:

Race:

Work Phone:

Occupation:

Household Information:

Household yearly income from all sources:

Own Rent
Apt. House

Number of rooms: Bedrooms:

Single Married
Date of marriage:

How many children under the age of eighteen
live in your home?

Ages: Sex:

Does anyone else reside in your home?

Additional Information:

What age range, sex, race, and number of children would best fit in your home?

What type of child are you interested in?

Briefly describe your reason(s) for wishing to become a foster parent:

Have you ever applied or been licensed for foster care? If so, when and with what agency?

Read Carefully
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that if employed, falsified statements on this application may be grounds for dismissal or denial of employment.

I understand and agree that I may be required to take a physical examination as a condition of hiring or continued employment; I understand and agree that in the event that I receive medical treatment for any condition, including a physical, psychological, emotional, or psychiatric condition that is job related, I hereby authorize the limited release and exchange of such medical information relating to my condition between the treatment provider an a company designated physician. I further agree to consent to be tested for illegal drugs prior to or during my employment. I agree to consent to take such tests and to release Frontline, it�s directors, officers, agents, or employees from any claim arising in connection with the use of such tests. I understand that Frontline has the duty to conduct a BCI/USSDS background check of all employees, and passing the background check is a requirement for continued employment.

I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you. I authorize Frontline, if applicable to request a copy of my credit report, motor vehicle driving record and any other investigative report they deem necessary through various third party sources. Upon my formal written request within a reasonable period of time, I will be notified as to the nature and scope of such investigation.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary be terminated at any time without prior notice. I have read and understand the above statement.

By submitting this application, I agree to the above