Locations/Schuylkill/Carbon Region
Foster Care Initial Contact Form

Serving Schuylkill and Carbon Counties

 

Enter your full name
Phone
Street Address 1
Street Address 2
City
State
Zip Code
Please select the county in which you reside:
 
Select area of interest:
•Lifesharing
•Foster Care
•Respite
•Any
•Undecided
 
Willing to participate in orientation:
Yes No 
 
How many people live in your household?
 
Please tell us the ages and relationships of those living in your household:
 
Can you provide a separate bedroom for the person to be placed in your home? 
yes   no
 
If no, what are the arrangements?
 
Are all the members of your household free from communicable diseases, to include, but not limited to, Hepatitis A, B, or C, AIDS, and tuberculosis?   
yes   no
 
Do you have a source of income to meet your and your family's needs: 
yes no
 
Are you willing to attend in-service training prior to approval? 
yes no
 
Have you ever worked with another agency? 
yes no
 
If yes, what is the name of the other agency, and in what capacity were you associated?
 
Are you currently providing day, foster or elderly care in your home? 
yes no
 
Do you have reliable transportation:  yes no
 
Do you have a valid driver's license?  yes no
 
Have you had any experience with individuals who either have a developmental disability, mental health concerns or learning difficulties?  Briefly describe:
 
Where did you hear about our program?
 
Please tell us where you saw or heard our ad.
 

 

 

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