form

City *

Name: *

Preferred Method of Contact

Phone

Email

How did you hear about us? *

Email: *

Zip *

A Place To Call Home requires that all pools and spas be fenced. Do you have a pool or spa?

Yes

No

Subject:

Check here if there's an identified child or adult for placement

If yes, please explain

If yes, is it fenced?

Yes

No

N/A

Are you at least 21 years or older?

Yes

No

Arizona Revised Statue ARS 8-804 requires that the Department of Economic Security maintain a central registry of reports of child abuse and neglect that are substantiated and that this information be used as one factor to determine qualifications for employees of contractors that provide direct service to children. Have you or a member of your family ever had a CPS (Child Protective Services) or DCS (Department of Child Safety) referral, involvement in a complaint involving CPS/DCS or have ever had a substantiated or unsubstantiated charge against you or a member of your family or family acquaintance or significant other in the last ten years? *

Yes

No

Phone *

If yes, please explain

If applicable, please tell us about any previous experience you have had with foster care or adoption, and include any previous licenses, trainings, or certifications:

Reason for interest in becoming a licensed foster home or developmental home or becoming respite or adoption certified *

What age range are you looking to care for?

Each adult in the household must be fingerprinted and obtain a Level 1 fingerprint clearance card. Does anyone have an arrest record or any type of activity that would come up on a background check? *

Yes

No