Please complete this form electronically (using your computer Microsoft Word program) and email to lmckay@kidnet.org.

1. FOSTER/ADOPTIVE PARENT APPLICATION
D
Date: ___/___/____ Foster/Adoptive Parent Respite Care
PERSONAL INFORMATION
Applicant(s):
Full Legal Name (Applicant 1) Full Legal Name (Applicant 2)
Address:
Street City County State Zip
Applicant 1 Phone:
Home Cell Work
Applicant 2 Phone:
Home Cell Work
Email (Applicant 1) Email (Applicant 2)
How long have you lived at the current residence? _____________
If less than three years please provide previous addresses for the last ten years.
Address:
Street City County State Zip
Address:
Street City County State Zip
Address:
Street City County State Zip
Marital Status: S
Single Married Separated Divorced Other _____
If married, divorced, or separated please provide the date:
Date of Birth (Applicant 1) Date of Birth (Applicant 2)
Social Security # (Applicant 1) Social Security # (Applicant 2)
Texas Drivers License (Applicant 1) Texas Drivers License (Applicant 2)
Languages Spoken (Applicant 1) Languages Spoken (Applicant 2)
Latest Revision 06/01/09 Page 1 of 6 file: CPA Policies/Forms/Foster Parent Files/Application

2. HOUSEHOLD INFORMATION
W
What type of dwelling do you live in? House A
Apartment Town House Condo Other: ________
D
Do you: Own Rent Lease Other: __________
How many square feet is your dwelling?
How many rooms and baths (i.e. 4 rooms - 2 bedrooms, one living/dining room, kitchen, one bathroom)?
D
Do any appliances use natural gas or propane? No
N Yes
I
If yes, which ones? H
Heater Stove Water Heater
S Other ___________
D
Do you have a safe place to store hazardous chemicals and cleaners? Yes No
Please explain how you would store such items, or how you would propose to store such items:
D
Do you have a weapon in the home (gun, swords, bow and arrows)? Yes No
If yes, please explain how the weapon is stored:
Members of the Household (Include ALL relative and non-relative members of the household)
Name Sex Date of Birth Relation Social Security #
Name Sex Date of Birth Relation Social Security #
Name Sex Date of Birth Relation Social Security #
Name Sex Date of Birth Relation Social Security #
(PLEASE ATTACH ADDITIONAL HOUSEHOLD MEMBERS IF NEEDED)
Children outside the home: (Include all adult and minor children outside the home)
Name Sex Date of Birth Relation Social Security #
Name Sex Date of Birth Relation Social Security #
Latest Revision 06/01/09 Page 2 of 6 file: CPA Policies/Forms/Foster Parent Files/Application

3. Name Sex Date of Birth Relation Social Security #
Name Sex Date of Birth Relation Social Security #
(PLEASE ATTACH ADDITIONAL HOUSEHOLD MEMBERS IF NEEDED)
Vehicle Information:
Year Make Model State License Plate #
Year Make Model State License Plate #
Year Make Model State License Plate #
A
Are these vehicles insured? Yes No
Which vehicle will be used for primary transportation of the child?
What type of insurance coverage do you have on that vehicle?
D
Do you own a three-wheeler or all terrain vehicle? Yes No
I
If yes, is it kept at the primary residence? Yes No
BACKGROUND INFORMATION
Applicant 1 Education:
High School:
Name/City Did you Graduate? Date
College/University:
Name/City Degree Date
Vocational/Business:
Name/City Trade/Certificate
Other:
Applicant 2 Education:
High School:
Name/City Did you Graduate? Date
College/University:
Name/City Degree Date
Vocational/Business:
Name/City Trade/Certificate
Other:
Employment History:
Applicant 1 Employment: (Past 5 Years)
Latest Revision 06/01/09 Page 3 of 6 file: CPA Policies/Forms/Foster Parent Files/Application

4. Date of Employment Employer Name/Address Position Salary Reason for Leaving
Date of Employment Employer Name/Address Position Salary Reason for Leaving
Date of Employment Employer Name/Address Position Salary Reason for Leaving
Applicant 2 Employment: (Past 5 Years)
Date of Employment Employer Name/Address Position Salary Reason for Leaving
Date of Employment Employer Name/Address Position Salary Reason for Leaving
Date of Employment Employer Name/Address Position Salary Reason for Leaving
Income and Expenses: Please include all forms of income from jobs, child support, alimony, investments annuities, savings accounts.
Annual Household Income:
Monthly Income:
Monthly Pay
Applicant 1 Applicant 2
Child Support
Applicant 1 Applicant 2
Alimony
Applicant 1 Applicant 2
Investments
Applicant 1 Applicant 2
Savings
Applicant 1 Applicant 2
Monthly Expense:
Monthly Mortgage/Rent
Applicant 1 Applicant 2
Auto Insurance
Applicant 1 Applicant 2
Home/Renter’s Ins
Applicant 1 Applicant 2
Life Insurance
Applicant 1 Applicant 2
Medical Insurance
Applicant 1 Applicant 2
Car payments
Latest Revision 06/01/09 Page 4 of 6 file: CPA Policies/Forms/Foster Parent Files/Application

5. Applicant 1 Applicant 2
Utilities
Applicant 1 Applicant 2
Other Loans
Applicant 1 Applicant 2
Special Interests-Hobbies:
Applicant 1, Tell us about your hobbies and interests:
D
Do you have any specialized skills or training? Yes No
If yes, Please tell us:
D
Doyou have any specialized skills or training? Yes No
If yes, Please tell us:
Military Service:
A
Applicant 1, Have you ever served in the Armed Forces? Yes No
If yes, Please tell us the dates, which service, and type of discharge:
COMMUNITY
W
What school district do you live in? GISD DISD MISD PISD RISD
D M P
Other:_______
What school would the foster/adoptive child attend?
T
Type: Public P
Private Charter
Level: Elementary:
Middle School:
High School:
What hospitals are near your home? What is the distance to your home?
What recreational facilities are near your home? What is the distance to your home?
D
Do you have city services in your area? (Please check all that apply)
911 P
Police Fire
F EMS WaterW
S
Sewer Storm Management
Latest Revision 06/01/09 Page 5 of 6 file: CPA Policies/Forms/Foster Parent Files/Application

6. In the event of a natural disaster, is there a shelter near your home? What is the distance to your home?
W
Would you be willing to take a child who does not speak English? Yes No
Y
What other community resources do you have in your area? What is the distance to your house?
Please name two persons or families that could provide emergency back up for you (i.e. extended family members or friends)
that would be willing to submit to criminal background checks, T.B. Tests, and have CPR and First Aid Training.
Family Member Family Member
I declare that all statements contained in this application are true and that any misrepresentations or an omission is cause for
rejection. I also authorize investigations of all statements contained in this application. I understand and agree that false
statements and or omissions regarding past conduct and or present situation may be grounds for denial of the application to
provide services and that refusal to inform the agency of the contents of a sealed criminal record will result in the automatic
denial of the application. I understand that by applying, I am not guaranteed the placement of a child in my home. By signing,
you are indicating that you have read and understand the above statement.
Signature: _______________________________________________ Date:___________
Signature: _______________________________________________ Date:___________
Please include the following with your application:
- A picture in front of your home with all family members and pets;
- A picture or drawing of where the child will be allowed to play outside in your yard;
- A drawing of your home indicating each room and its purpose and also indicating which room will be the child’s or
children’s room;
- W-2’s and Tax Returns for the last two years; and
- Credit Report (not over 90 days old)
Latest Revision 06/01/09 Page 6 of 6 file: CPA Policies/Forms/Foster Parent Files/Application