CAREGIVER APPLICATION UNITY #_________________ Division of Child & Family Services (DCFS) Clark County Department of Family Services (DFS) Washoe County Department of Social Services (WCDSS) Be sure that this application is completed in full and all required “separate sheet” attachments have been provided. Foster Care Application for (check all that apply): ICPC How did you learn about the program: T.V. Adoption Contractor Radio Relative/Specific Name:____________________________ (Name of contract agency)____________________________________________ Newspaper Friend Relative Agency/Court Foster Parent Other _____________________________________________________________________________________________ Applicant #1 Name (First) _________________________ (Middle)___________________ (Last) ____________________________________ Date of birth Place of birth: City, ________________ State, ________ Country, _____________ _______________________________________________________________________ Social Security #______________________ Driver’s Lic. #_______________________State_____________ RACE/ETHNICITY: Cauc. African American Native American/Alaskan Native Are you a US Citizen? Yes Asian/Pacific Isl. No Legal Resident? Other Identify)_________________________ __________________ Tribal Tribe Hispanic / Member Number: ______________________ Yes No If “Yes”, Resident number ____________________ What languages do you speak? ____________________________________________ Occupation___________________________ Employer ______________________________Address___________________________________________________ Work phone______________________ How long at current job (If less than five years, please list employment history for past five years by attaching a separate sheet) Do you have health insurance? Yes No If yes, Agency _________________________________________________ Would your health insurance cover an adopted child? Yes No Applicant #2 Name (First)____________________ (Middle) _________________ (Last) ___________________________________ Place of birth: City, _________________ State, ________ Country, ____________ Date of birth Social Security #______________________ Driver’s Lic. #_______________________ State____________ RACE/ETHNICITY: Cauc. Native American/Alaskan Native Are you a US Citizen? Yes African American Asian/Pacific Isl. Other (Identify)_________________________ _____________________ Tribal Tribe No Hispanic Legal Resident? Yes / Member Number:_________________ No If “Yes”, Resident number _______________________ What languages do you speak? __________________________________ Occupation _________________________ Employer _____________________________ Address___________________________________________________ Work phone______________________ How long at current job (If less than five years, please list employment history for past five years by attaching a separate sheet) Do you have health insurance? Yes No If yes, Agency ______________________________________________ Would your health insurance cover an adopted child? Yes No Residence: House Apartment Condo Mobile Home if mobile home, year built____________ Do you own your home or rent? Own Rent Other (specify) ___________________________________ Total square feet in residence How long at this residence?_______________________ Residence address _____________________________________________City _________________State__________ County ______________________ Residence phone ( ) Zip_____________ Mailing address (If different)____________________________________________City ________________ State__________ Please provide detailed directions to your residence Email _________________________________________ Zip______________ Cell phone ( )_____________________________ (Applicant #1) Cell phone ( )_________________________ (Applicant #2) 1 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION UNITY #_________________ List previous addresses for the past 10 years (Include City, State & Zip – use separate sheet if needed) Check if for FROM 1 Address Applicant TO 5 Address FROM Check if for TO Applicant 1 2 1 2 1 2 2 FROM TO 6 FROM TO 1 2 1 2 3 FROM TO 7 FROM TO 1 2 1 2 4 FROM TO 8 FROM TO 1 2 List ALL household members (In “Relationship to applicant” space list son, daughter, stepson etc.) Social security # Name Birth date Social security # Name Relationship to Applicant #1 #2 1 9 5 #2 8 4 #1 7 3 Relationship to Applicant 6 2 Birth date 10 List extended family for Applicant #1 not living in the home (Include children, parents, brothers and sisters) Name of extended family Age Relationship Occupation Phone with area code Address 1 2 3 4 5 6 7 List extended family for Applicant #2 not living in the home (Include children, parents, brothers and sisters) Name of extended family Age Relationship Occupation Phone with area code Address 1 2 3 4 5 6 7 List household’s average monthly income ( list all sources of income & attach documentation of this income) Applicant #1 Net monthly Gross monthly $ $ $ $ Source $ $ $ $ $ $ $ $ Assets Checking $ Stocks/bonds Trust Other Other $ $ $ $ Applicant #2 Net monthly Gross monthly Checking $ Savings $ Real Estate $ Annuity Type Savings $ Stocks/bonds $ Source $ $ $ $ $ Real Estate $ $ Annuity $ Type $ Total combined monthly household income $ Trust Other Type 2 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION UNITY #_________________ Has Either applicant declared bankruptcy? Applicant #1 Yes No Applicant #2 Yes No Location where order was filed________________________________________ Date__________________________ (Attach bankruptcy disposition court order) Household expenses: Enter your household’s average monthly expenses (Do not include expenses that are deducted from paychecks) House/Rent payments Utilities Telephone Gasoline / Auto maintenance Automobile payments Automobile insurance Groceries & household supplies Credit card payments $ $ $ $ $ $ $ $ Child support payments Loans outstanding Payments for other real estate Recreation & entertainment Life insurance Medical & dental insurance Medical care (not covered by insurance) Dental care (not covered by insurance) $ $ $ $ $ $ $ $ Child care Clothing Other $ $ $ Total Monthly Expenses $ 1. Have you ever applied to provide foster care? Applicant #1 Yes No Applicant #2 Yes No Name of agency you applied with: ______________________________________________________ Date __________________________ Address of agency____________________________________________________________City________________________State___________ 2. Have you ever applied for a childcare license? Applicant #1 Yes Applicant #2 No Yes No Name of agency you applied with: _________________________________________________________ Date__________________________ Address of agency_____________________________________________________________City_______________________State__________ 3. Have you ever applied to adopt a child? Applicant #1 Yes Applicant #2 No Name of agency you applied with: ________________________________________________________ Yes No Date _________________________ Address of agency_____________________________________________________________City_______________________State__________ 4. Have you ever applied for a license to provide care for adults or children? Applicant #1 Yes No Applicant #2 Yes No Name of agency you applied with:_________________________________________________________ Date__________________________ Address of agency_____________________________________________________________City_______________________State__________ NOTE: Section 106 of the Federal Adoption and Safe Families Act: a record check revealing a felony conviction for child abuse/neglect, or spousal abuse, or a crime against children (including child pornography), or a crime involving violence, including rape, sexual assault, or homicide, but not including other physical assault or battery, and a court of competent jurisdiction has determined that the felony was committed at any time, such final licensure approval shall not be granted; in any case in which a record check reveals a felony conviction for physical assault, battery or a drugrelated offense, and a court of competent jurisdiction has determined that the felony was committed within the past 5 years, such final licensure approval shall not be granted. A “YES”ANSWER TO ANY QUESTIONS BELOW REQUIRES ATTACHMENT OF A SEPARATE SHEET TO PROVIDE DETAILS * SEE PAGE 5 FOR DETAILED INFORMATION REQUIRED 5. Has ANY household member been treated or is being treated for a psychological condition? (Use separate sheet if needed) Date Treatment end date Person treated Condition or diagnosis Treating physician diagnosed Applicant # 1 Yes No Applicant # 2 Yes No Household member Yes No Name: 6. Has ANY household member been prescribed medication for psychological/ mental health condition? (Use separate sheet if needed) Length of time medication used Treating physician Person treated Medications Medications Applicant # 1 Yes No Applicant # 2 Yes No Household member Yes No Name: 7. Has ANY household member ever been arrested, convicted or currently facing charges, for ANY law enforcement violation/offense? Applicant #1 Yes NO Applicant #2 Yes No Other household member Yes No Date______________________ Name____________________________________________ Name of arresting agency: _________________________________________ Agency address ___________________________________City County _________________ State______ 7.a Is ANY household member currently or previously on parole or probation for an offense? Applicant #1 Yes No Applicant #2 Yes No Other household member Yes No (Name)_______________________________________ Agency __________________________________________City County _________________State______ 8. Was ANY household member ever investigated for child abuse or neglect by child protective services or law enforcement? Applicant #1 Yes No Applicant #2 Yes No Other household member Yes No (Name)_________________________________ Name of investigating agency _______________________________________________ Date of investigation _________________ Agency address ____________________________________City County _________________State______ 3 American LegalNet, Inc. www.FormsWorkFlow.com Revised 3/06 CAREGIVER APPLICATION Residence floor plan UNITY #_________________ (Please draw a floor plan, label the rooms and indicate square footage of each bedroom.) 4 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION UNITY #_________________ References Please list seven references that have known you for at least three years. No more than two of the seven may be relatives. Please be sure to include name, full mailing address including zip code, telephone number, relationship and the number of years known. 1. Name Full Address Relationship Phone Number ( ) Years Known Zip 2. Name Relationship Full Address 3. Name Relationship Full Address 4. Name Relationship Full Address 5. Name Relationship Full Address 6. Name Relationship Full Address 7. Name Relationship Phone Number Full Address ( ) Years Known Phone Number ( ) Years Known Phone Number ( ) Years Known Phone Number ( ) Years Known Phone Number ( ) Years Known Phone Number ( ) Years Known Zip Zip Zip Zip Zip Zip Attachments to the application: As necessary attach copies of the following documents. Final disposition cannot be determined until ALL required documents have been returned. (PLEASE check all attachments you have included.) Social Security Card (s) Driver’s License (s) Automobile insurance Immigration card (s) if applicable Documentation of monthly income, i.e., pay stubs, most recent tax return, or other. Marriage certificate if applicable Divorce decree(s) if applicable Permits for well/septic systems if applicable Current immunizations for all pets Bankruptcy disposition order, if applicable Employment history for past 5 years if applicable Proof of TB testing for each applicant & household members 18 years of age or older Recent photographs of all household members Photographs of all bodies of water on the property where you live Proof of CPR training if applicable SAFE Questionnaire # 1 (completed) Homeowner’s insurance (if you own your home) Renter’s insurance and landlord’s written permission for children to be in the home (If you rent your residence) OTHER______________________________________________________________________________________________________ For any “YES” answer to QUESTIONS #5 THROUGH #8, an attachment is required as outlined below Explanation/listing of medication *Attachment required. Provide history of illness causing use of medication and name of attending physicain. Signed release of information from attending physician may be required. Explanation/listing of psychiatric treatment/condition *Attachment required. If psychiatric condition is identified, attending physian must provide written proof of ability to provide care. A Signed release of information from attending physician may be required. Criminal background/CPS history *Attachment required. Provide dates, circumstances and results of any CPS or criminal investigation. List all charges, arrests, disposition of arrest, if on parole/probation, name of parole officer and agency. Indicate all felony or misdemeanor arrests. Explain any child removed from your care or any termination of parental rights vs. you/current or previous partner. I/WE DECLARE that the information supplied in this application is complete and true. I/We understand that any incomplete or false information WILL result in an immediate rejection of my/our application. Signatures Applicant #1 Date______________ Applicant #2______________________________________ Date______________ 5 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com CAREGIVER APPLICATION Office use only: Date received Assigned worker Comments: Office location: Date assigned______________ UNITY #_________________ Agency SAFE Q-1 returned Yes  No ________________________________________________________________________________________________________ 6 Revised 3/06 American LegalNet, Inc. www.FormsWorkFlow.com DIVISION OF CHILD AND FAMILY SERVICES STATEMENT OF APPLICANT(S) RESPONSIBILITY THIS IS AN AGREEMENT BETWEEN Division of Child and Family Services (AGENCY) AND _____________________________________________________ (FOSTER/ADOPTIVE CAREGIVERS(S)), FOR THE PROVISION OF FOSTER CARE SERVICES TO CHILD(REN) PLACED IN CARE. I. Serve as an active member of the service delivery team. The foster/adoptive caregiver(s) will: 1. Adhere to the Division’s policy on discipline as defined in the NAC regulation. 2. Participate in case planning conferences, team meetings, and foster care review board meetings, if applicable. 3. Closely observe and document the foster child’s behavior so that it can be clearly and specifically communicated to the service delivery team. 4. Inform the caseworker of any special needs of the child, including educational, treatment, physical, etc. 5. Encourage the foster child to communicate with the caseworker. 6. Build a relationship with the primary family of the child to encourage that relationship and facilitate reunification, if called for in the case plan. 7. Encourage visitation between the child and the primary family, if called for in the case plan. 8. Before requesting the removal of the child from the home, make every effort to maintain the child’s current placement. Request an emergency team meeting regarding the requested removal, if needed. 9. Respect the final decision made by the consensus of the service delivery team. II. Meet the child’s basic daily needs. The foster/adoptive caregiver(s) will: 1. Provide for the child: food, shelter, recreational opportunities, education as required, maintenance of clothing, and transportation as defined in the case plan 2. Provide for the child: guidance, discipline, moral instruction, and/or opportunity for religious practices and normally observed holidays and special occasions. 3. Instruct the child in good health and hygiene habits. 4. Respect each child as a unique individual and offer nurturing, loving care, which enhances the child’s positive qualities. 5. Transport and accompany the child to medical and dental appointments. 6. Investigate and encourage the development of the child’s participation in community activities. 7. Assist in preparing the child for transition to the primary family, adoptive family, independent living, or other living arrangements. 8. Have a plan acceptable to the agency for the provision of care and supervision of the child by a competent person whenever caregiver(s) is absent from the home. 9. Keep running notes and/or questions of important matters in order to have the most productive discussions with the caseworker at monthly home visits. 10. Develop and maintain a lifebook for each foster child to chronicle their life while in substitute care and ensure that it goes with the child to each placement. American LegalNet, Inc. www.FormsWorkFlow.com III. Confidentiality The foster/adoptive caregiver(s) will: 1. Respect the confidentiality or information concerning the child’s and/or his/her family’s physical, mental, and social background, or the child’s past or present problems, and to share this information only with appropriate persons specifically authorized by the agency. 2. Inform the child and primary family that information they give may need to be shared with the caseworker, especially if the information could lead to harm to the child or others. IV. Training The foster/adoptive caregiver(s) will: 1. Complete all pre-service and in-service training as required for licensing. V. Policies and Procedures The foster/adoptive caregiver(s) will: 1. Be licensed in accordance with the rules of the Division of Child and Family Services, and comply with all the rules. 2. Be aware and familiar with, adhere to and keep apprised of foster care regulations and standards. 3. Give the agency adequate notice (i.e., five (5)) working days when requesting removal of a child from the home, except where there is an immediate danger to the foster child or others if the child is not removed. 4. Adhere to the Division’s policy on discipline as defined in the NAC regulations. I (WE) HAVE READ AND AGREE WITH THE CONTENTS OF THIS DOCUMENT: APPLICANT I DATE APPLICANT II DATE DIVISION REPRESENTATIVE DATE American LegalNet, Inc. www.FormsWorkFlow.com DIVISION OF CHILD AND FAMILY SERVICES STATEMENT OF APPLICANT(S) AGREEMENT I (We) agree the Division of Child and Family Services cannot issue a Foster Home License nor place children with us without our agreement to the following conditions. I (We) voluntarily agree: 1. To report to the Division any change of address before moving, sickness in the family or changes in the family household and sickness of, or accident to, child or children placed with us. 2. To treat the child or children whom we may receive for Foster Care as members of our family. 3. To secure permission of the supervising agency before making plans for taking the child or children out-of-state. 4. To carry out instructions of the supervising agency for care of the child and to cooperate with the division in maintaining standards. 5. To allow the representative of the Division and/or supervising agency to visit this home. We agree the Division and/or supervising agency may make unannounced home visits. 6. That the Division has the responsibility to make and carry out plans for the transfer of children placed in our home to other homes, adoption, return to relatives or other disposition as may appear to the Division to be for the best interest of any child placed with us. These transfer plans will be discussed with us, along with our observations and recommendations, to assist the Division to make the most appropriate plan for the child. 7. That the reasons for refusal to accept the placement of a child in our home cannot be based on race, religion, ethnic origin or handicap. 8. To obtain any required training before licensure or re-licensure. 9. To maintain the child’s confidentiality per NAC 424.485. The information given in our application is true and complete to the best of our knowledge. We each have read and agree to comply with this statement of agreement and all other rules as set forth in the Nevada Foster Care requirements (NAC 424), of which we have received a copy. I (We) have received a signed copy of the statement of agreement for our records. Applicant I Date Applicant II Date I have discussed this statement of agreement with each of the above applicant(s), as well as those Nevada Foster Care Requirements for which clarification was requested. Division Representative Date APPLICANT COPY American LegalNet, Inc. www.FormsWorkFlow.com DIVISION OF CHILD AND FAMILY SERVICES STATEMENT OF APPLICANT(S) UNDERSTANDING I, ____________________________________ and I, ____________________________________ Understand the Division’s primary concern is to find the best possible home for each child, therefore: 1. An application for Adoption, Foster Care of ICPC does not guarantee an approval for placement of a child. An approval or denial is based on the suitability of the family for children for whom the Division as responsibility. 2. If my/our application is approved, I/we are not guaranteed the placement of a child in my/our home. 2. I/We hereby certify the foregoing facts are true and accurate to the best of my/our knowledge. I/We understand that any falsifying of information may result in an immediate denial of this application. APPLICANT I DATE APPLICANT II DATE American LegalNet, Inc. www.FormsWorkFlow.com Jim Gibbons Governor Michael J. Willden Director Department of Health and Human Services STATE OF NEVADA Diane J. Comeaux Administrator DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF CHILD AND FAMILY SERVICES AUTHORIZATION BY APPLICANT(S) FOR RELEASE OF PROTECTED HEALTH INFORMATION OR CONFIDENTIAL INFORMATION REGARDING: NAME ____________________________________ SOCIAL SECURITY NUMBER NAME ____________________________________ SOCIAL SECURITY NUMBER You are authorized by the undersigned to release to the Division of Child and Family Services, the information including but not limited to that indicated below. This authorization constitutes a full and complete release from any liability resulting from disclosure of such information. This authorization also permits release of medical information under the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255) and Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act amendments of 1974 (P.L. 93-282). A photocopy of this form shall be as valid as the original. This authorization shall be in force and in effect until which time this authorization to use or disclose this protected health/confidential information expires. This authorization shall be valid for one year from the date signed, unless otherwise specified. DATA REQUESTED: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ____________________________________ SIGNATURE DATE ____________________________________ SIGNATURE Please return this request to: DATE Division of Child and Family Services American LegalNet, Inc. www.FormsWorkFlow.com