TREATMENT FOSTER PARENT INQUIRY

Applicant Information
Full Name:
Last						First			M.I.
Address:
		Street Address							Apartment/Unit #
		City						State	ZIP Code
Home Phone:			( )		Cell Phone
Other Information about you and your family :
Voluntary Information
Please indicate what type of contact you desire:
	Informational packet (mail)			Schedule an orientation
	Telephone Call			Other: _________________ kjid=__________________________________________
Are you currently licensed as a foster parent?
	YES			NO
How Many Children reside in the Home?
	0			2
	1			3 or more
How did you hear about this website?
	Newspaper			Company Employee			General Internet Search
	Current foster parent			DHS/Court Employee			Accident
	Other