Treatment Home Applications



0000CLARK COUNTY DEPARTMENT OF FAMILY SERVICESAGENCY FAMILY FOSTER HOME APPLICATIONThis application is for a foster home that is supported by a foster care agency. A family foster home accepts children into their own home which must also be their primary residence. The home can be supported by agency staff but the parents are the primary caregivers in the home and their names are on the license. A home study is required for family foster homes. Bed capacity in such a home can be from one (1) to six (6) beds. Completed Application includes (copies of documents are acceptable):Agency Foster Home Cover Sheet – fill in all dates and informationApplication for Agency Family Foster Home – complete all sectionsIf applicant has any history of DFS Hotline complaints, provide explanations of each. Copies of reports do not need to be submitted and are only needed if applicant can’t recall history. Contact DFS Records Dept at (702) 455-6683 to obtain records if necessaryIf applicant has any arrest history regardless of disposition, provide the following:Written explanation from applicantCourt disposition recordsFingerprint receipt showing applicant printed for specific agencyNV Driver’s License or NV Identification Card for non-driver--clear copy to show faceTB test ResultsCopy of Social Security cardCPR Card– Adult, Child and Infant CPR (cannot be from an online course)Proof of valid and current automobile insurance for any driversTraining log—Include completion certificates for any online trainingsFive (5) references, no more than 2 related and all must have known applicant for at least 2 yearsVerification of Income/Savings for most recent 3 months (paystubs, bank statements, tax returns)Marriage/Domestic Partnership CertificateDivorce Decree(s) – 1st and last page onlyBankruptcy Discharge paperwork (if bankruptcy ever filed)Floor plans showing emergency exit routesCopy of entire lease if rentingHomeowners/Renter’s Insurance (required)2 Utility bills dated within the most recent 3 months (preferably electric and gas)Family photo, including pets and any non-primariesFire Extinguisher-Need purchase or re-charge receipt (minimum rating 2-A 10BC)Completed Home Study and all supporting documentsPet Shot Records and/or Statement from Veterinarian if pet can’t be immunizedImmunization Records for any minors residing in the home (does not include foster children)Emergency/Disaster FormAgency Foster Home Cover SheetAgency: HOME TYPE: FAMILY FOSTER HOMELICENSE TYPE: FORMCHECKBOX Initial FORMCHECKBOX Relocation FORMCHECKBOX Re-Open FORMCHECKBOX Renewal FORMCHECKBOX Non-RenewalProvider # FORMTEXT ?????Applicant #1 Name: FORMTEXT ?????Cell: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Work: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Applicant #2 Name: FORMTEXT ?????Cell: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Work: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Address: FORMTEXT ?????City: FORMTEXT ?????State: NVZip: FORMTEXT ?????Email: FORMTEXT ?????Landline Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? Non-Primary #1 Non-Primary #2 Name: FORMTEXT ????? Name: FORMTEXT ?????Applicant #1Applicant #2 FORMCHECKBOX Live In FORMCHECKBOX Non-Live In FORMCHECKBOX Live In FORMCHECKBOX Non-Live In FORMCHECKBOX Direct Care FORMCHECKBOX Non-Direct FORMCHECKBOX Direct Care FORMCHECKBOX Non-Direct Adam Walsh State(s): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Fingerprint- Receipt Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Scope (DFS USE ONLY) FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????CANS (DFS USE ONLY) FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????A. Arrest History (If yes, must provide B & C) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoB. Explanation from Applicant FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoC. Final Disposition FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No EXPIRATION DATE EXPIRATION DATE EXPIRATION DATE EXPIRATION DATE Applicant #1Applicant #2Non-Primary #1Non-Primary #2NV Driver’s Lic or NV Identification Card FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????TB Test Due Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????CPR Due Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Auto Insurance Exp Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Homeowners / Renters Insurance Exp Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Photo of Non-Prim FORMCHECKBOX Photo of Non-Prim FORMCHECKBOX Training Log FORMCHECKBOX 40 hrs FORMCHECKBOX 20 hrs FORMCHECKBOX 40 hrs FORMCHECKBOX 20 hrs FORMCHECKBOX 40 hrs FORMCHECKBOX 20 hrs FORMCHECKBOX 40 hrs FORMCHECKBOX 20 hrsRelease of Information FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Social Security Card FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Total # References: FORMTEXT ??Relative: FORMTEXT ?? Relative: FORMTEXT ?? Relative: FORMTEXT ?? Relative: FORMTEXT ?? Non Relative : FORMTEXT ??Non Relative : FORMTEXT ??Non Relative : FORMTEXT ??Non Relative : FORMTEXT ??Verification of Income FORMCHECKBOX FORMCHECKBOX Marriage Certificate (Date) FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????NOTES: FORMTEXT ?????Maiden Name FORMTEXT ????? FORMTEXT ?????Divorce Decree FORMCHECKBOX FORMCHECKBOX Bankruptcy Discharge Paperwork (if applicable) FORMCHECKBOX FORMCHECKBOX Floor Plans FORMCHECKBOX Exit Route Marked Emergency Disaster Form FORMCHECKBOX Copy of Lease (If Renting) FORMCHECKBOX 2 Utility Bills w/in last 3 months FORMCHECKBOX Photo of Family FORMCHECKBOX Fire Extinguisher Purchase/Last Service Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????Immunization Records of Minors Residing in Home FORMCHECKBOX Completed Home Study FORMCHECKBOX Total # of Pets: FORMTEXT ????? FORMCHECKBOX Waiver FORMCHECKBOX ApprovalNAC 424. FORMTEXT ?????NAC 424. FORMTEXT ?????Date Approved FORMTEXT ????? or Date Denied FORMTEXT ?????Pet Name: FORMTEXT ?????Pet Photo: FORMCHECKBOX Shots Due: FORMTEXT ?????Pet Name: FORMTEXT ?????Pet Photo: FORMCHECKBOX Shots Due: FORMTEXT ?????Pet Name: FORMTEXT ?????Pet Photo: FORMCHECKBOX Shots Due: FORMTEXT ?????Clark County Department of Family ServicesAgency Family Foster Home ApplicationPurpose: An Agency Family Foster Home is a foster home that has been fully licensed by Clark County Department of Family Services (DFS) and has been approved to provide higher level of care services above and beyond those of a traditional family foster care home. Children placed in these homes will typically have a psychiatric diagnosis, be on psychotropic medications and have multiple behavioral issues. These homes must meet the following conditions:Can be only licensed up to a maximum of six (6) children – Total number is excluding biological and/or adopted children. Best practice is no more than two (2) unrelated higher level of care foster children per licensed home.Must meet the 1 adult to 6 children supervision ratio which does include all other minor children residing in the home.Must meet all minimum licensing standards and must complete additional application requirements which demonstrate the family’s qualifications to provide treatment level services; andMust participate, and successfully complete, initial (40 hours) and annual (20 hours) training according to the requirements of foster care regulations outlined in Nevada Administrative Code (NAC) Chapter 424.An Agency Family Foster Home is generally (but not exclusively) a home that is operated by foster parents who live full time in the home being licensed as their primary residence and who have additional training and expertise in working with children who have specialized needs.Agency Family Foster Homes contract with and are supported by a parent agency. This agency is generally a corporation (either for profit or non-profit) that has a valid contract with DFS to provide higher level of care services for children in the child welfare system and to recruit and train foster parents. Applicants must apply through a contracted agency and meet their requirements as well as those of DFS. This application packet has all required instructions and materials needed to apply for an Agency Family Foster Home license. General InstructionsApplicants seeking to become foster parents as a foster home under an approved agency umbrella must submit this application to the responsible agency, which will then send all application materials to DFS Licensing. Applicants need to be sure they are fingerprinted for the purpose of being licensed through the agency they are applying with (not for DFS foster care). Applicants who were previously cleared with another agency or DFS still need to be fingerprinted for the agency they are applying with. Fingerprint appointments can be made at 702-455-5146.Applicants should seek guidance from their agency representatives for any questions on how to fill out the application.Applicants should keep a completed copy of their application materials for future reference. Completed application packets should be forwarded by the agency to:Clark County Department of Family Services; Agency/Group Home Licensing Unit500 South Grand Central Parkway, 5th Floor, Las Vegas, Nevada, 89155Name of Parent Agency: FORMTEXT ?????Type of Application: Family Foster HomeResidence Information:Residence Address: FORMTEXT ?????City: FORMTEXT ?????State: NVZip: FORMTEXT ?????Type of Residence: FORMCHECKBOX House FORMCHECKBOX Apartment FORMTEXT ?????Floor FORMCHECKBOX Condominium FORMCHECKBOX Mobile HomeDo you own or rent? FORMCHECKBOX Own FORMCHECKBOX Rent FORMCHECKBOX Other (explain) FORMTEXT ?????Square Footage of Residence: FORMTEXT ?????Length of Time at Residence: FORMTEXT ?????Mailing Address (if different): FORMTEXT ?????City: FORMTEXT ?????State: NVZip: FORMTEXT ?????Landline Phone #: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Community Gate Code: FORMTEXT ?????APPLICANT #1APPLICANT #2Full Name: FORMTEXT ????? FORMTEXT ?????Alias, Maiden, or Other Names Used: FORMTEXT ????? FORMTEXT ?????Cell Phone #: ( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????Email Address: FORMTEXT ????? FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX FemaleDate of Birth: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????City, State; Country of Birth FORMTEXT ?????, FORMTEXT ????? ; FORMTEXT ????? FORMTEXT ?????, FORMTEXT ????? ; FORMTEXT ?????Social Security Number: FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ????Driver’s License or ID Card # FORMTEXT ????? FORMTEXT ?????State Issued By: FORMTEXT ????? FORMTEXT ?????Race: FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Asian FORMCHECKBOX Black/African American FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX White/Caucasian FORMCHECKBOX Other (specify) FORMTEXT ????? FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Asian FORMCHECKBOX Black/African American FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX White/Caucasian FORMCHECKBOX Other (specify) FORMTEXT ?????Ethnicity: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Non-Hispanic or Latino FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Non-Hispanic or LatinoIf Native American/Alaskan Native Tribe, provide Tribe & Member number: FORMTEXT ????? FORMTEXT ?????Religion/Faith: FORMTEXT ????? FORMTEXT ?????Are you a US Citizen? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Are you a Legal Resident?If “yes,” provide ID #: FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, ID # FORMTEXT ????? FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, ID # FORMTEXT ?????Language(s) Spoken: FORMTEXT ????? FORMTEXT ?????Highest Level of Education: FORMTEXT ????? FORMTEXT ?????Occupation: FORMTEXT ????? FORMTEXT ?????Employer: FORMTEXT ????? FORMTEXT ?????Employer Address: FORMTEXT ????? FORMTEXT ?????Work Phone:( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????( FORMTEXT ???) FORMTEXT ??? - FORMTEXT ????How long at current job? FORMTEXT ????? FORMTEXT ?????Work hours: FORMTEXT ????? FORMTEXT ?????Do you have health insurance? FORMCHECKBOX Yes FORMCHECKBOX No If yes, Insurer Name FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No If yes, Insurer Name FORMTEXT ?????Would your health insurance cover an adopted child? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No List Addresses for Previous 5 Years (most recent first): (Use additional pages if necessary)CHECK IF FOR APPLICANTSTREET ADDRESS, CITY, STATE, ZIP CODEDATE#1#2FROMTO FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List ALL Household Members: (Use additional pages if necessary)NameDate of BirthSocial Security # GenderRaceRelationship to Applicants (son, stepdaughter, etc.)#1#2 FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX Female FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List Anyone NOT Living in the Home Who May Frequent the Home Regularly:NameDate of BirthAddressPhoneRelationship to Applicants(child, parent, sibling)#1#2 FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ?????( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ?????( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ?????( FORMTEXT ???) FORMTEXT ???- FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Household Income (please attach documentation proving all listed sources of income)Monthly Net Income (Take Home after taxes)Applicant #1Applicant #2Total1st Job Income$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????2nd Job Income $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Social Security/SSI/SSDI$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Child or Spousal Support$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Unemployment Compensation$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Workers’ Disability Compensation$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Veterans Benefits$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Retirement Benefits$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Monies from Boarders or Roommates$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Child Care Assistance$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Housing Assistance$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Rental Income $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other, please specify: FORMTEXT ????? $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other, please specify: FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY INCOME $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Applicant #1Applicant #2TotalChecking Account(s)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Savings Accounts(s) $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Stocks/Bonds$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Trust/Annuity$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Real Estate$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????TOTAL HOUSEHOLD ASSETS$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Applicant #1Applicant #2Have you ever applied for bankruptcy? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No Location and chapter of bankruptcy State: FORMTEXT ????? Chapter: FORMTEXT ?????State: FORMTEXT ????? Chapter: FORMTEXT ?????Date order was filed/discharged (attach disposition) FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????Monthly Household ExpensesSHELTERINSURANCE/HEALTH CAREMortgage/Rental Payment (include HOA)$ FORMTEXT ?????Life/Auto/Property $ FORMTEXT ?????Home Maintenance$ FORMTEXT ?????Medical/Dental (include prescriptions and expenses not covered by insurance)$ FORMTEXT ?????Taxes/Insurance (if not included)$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????TRANSPORTATIONFOOD & HOUSEHOLD Gas/Repairs/Maintenance$ FORMTEXT ?????Groceries/Beverages$ FORMTEXT ?????Registration$ FORMTEXT ?????Cleaning Supplies/Paper Products$ FORMTEXT ?????Bus/Carpool $ FORMTEXT ?????Food Away from Home/Restaurants$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????Tobacco/Alcohol $ FORMTEXT ?????MONTHLY OBLIGATIONSOther: FORMTEXT ?????$ FORMTEXT ?????Alimony/Child Support$ FORMTEXT ?????UTILITIES Total Auto Loans$ FORMTEXT ?????Gas/Water $ FORMTEXT ?????Total Credit Cards $ FORMTEXT ?????Power $ FORMTEXT ?????Other: FORMTEXT ????? $ FORMTEXT ?????Cell/Mobile Phone/Internet Services$ FORMTEXT ?????PERSONAL CARE Phone (Landline) $ FORMTEXT ?????Beauty/Barber Shop $ FORMTEXT ?????Cable$ FORMTEXT ?????Other$ FORMTEXT ?????Garbage/Sewer $ FORMTEXT ?????OTHER EXPENSES FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????Pets (Boarding/Food/Vet) $ FORMTEXT ?????RECREATION Clothing/Shoes $ FORMTEXT ?????Movies/Hobbies$ FORMTEXT ?????Babysitting/Daycare $ FORMTEXT ?????Vacations$ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????Entertainment $ FORMTEXT ?????Other: FORMTEXT ?????$ FORMTEXT ?????TOTAL MONTHLY EXPENSES$ FORMTEXT ?????TOTAL MONTHLY INCOME$ FORMTEXT ?????TOTAL MONTHLY EXPENSES $ FORMTEXT ?????Applicant #1Applicant #21. Have you ever applied to provide foster care? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No If yes, Name of agency you applied with: FORMTEXT ?????Date: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????Address of agency: FORMTEXT ?????City: FORMTEXT ????? State/Zip: FORMTEXT ????? Applicant #1Applicant #22. Have you ever applied for a childcare license? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No If yes, Name of agency you applied with: FORMTEXT ?????Date: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????Address of agency: FORMTEXT ?????City: FORMTEXT ????? State/Zip: FORMTEXT ????? Applicant #1Applicant #23. Have you ever applied to adopt a child? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No If yes, Name of agency you applied with: FORMTEXT ?????Date: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????Address of agency: FORMTEXT ?????City: FORMTEXT ????? State/Zip: FORMTEXT ????? Applicant #1Applicant #24. Have you ever applied for a license to provide care for adults or children? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No If yes, Name of agency you applied with: FORMTEXT ?????Date: FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????Address of agency: FORMTEXT ?????City: FORMTEXT ????? State/Zip: FORMTEXT ????? 5. Has ANY household member previously been treated for or is currently being treated for a psychological/psychiatric condition? FORMCHECKBOX Yes FORMCHECKBOX No If yes, attach explanation/listing of treatment/condition; attending physician must provide written proof of ability to provide foster care; a signed release of information from attending physician may be required.Person TreatedCondition or DiagnosisDate DiagnosedTreatment End DateTreating Physician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?????6. Has ANY household member ever been prescribed any medications? FORMCHECKBOX Yes FORMCHECKBOX No If yes, attach explanation/listing of medication; provide history of illness causing use of medication and name of attending physician; a signed release of information from attending physician may be required.Person TreatedCondition or DiagnosisMedicationLength of Time Medications UsedTreating Physician FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. Has ANY household member EVER been arrested, charged and/or convicted for ANY law enforcement violation? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide the specific details on a separate page, listing ALL arrests, even if the charges were later dismissed or expunged. Provide the date of arrest, circumstances and final dispositions. Also provide copies of all court records that verify the final disposition of the arrest.Name of Household MemberDateName of Arresting AgencyAddress of Arresting Agency (including City, State, Zip) FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????8. Is ANY household member currently or was previously on parole or probation for an offense? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide the specific details on a separate paper, listing ALL arrests, even if the charges were later dismissed or expunged. Provide the date of arrest, circumstances and final dispositions. Also provide copies of all court records that verify that the probation/parole period is over. If on parole/probation, provide name of parole officer and agency.Name of Household MemberAgency NameAddress (including City, State, Zip) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. Has ANY household member EVER had Child Protective Services, Foster Care Licensing or Child Welfare Agency involvement for allegations of child abuse and/or neglect? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please provide an explanation for each event on a separate page to include dates, circumstances, and results of any allegations made. Explain any child removed from your care or any termination of parental rights of you, current or previous partner. Name of Household Member or Previous PartnerDate of InvestigationName of Investigating AgencyAddress of Agency (including City, State, Zip) FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????Residence floor plan: (Please draw a floor plan, label the rooms and indicate square footage of each bedroom. Use arrows to show emergency exit routes.) A copy of a floor plan on a separate page is also acceptable. Caregiver Matching FormThe purpose of this form is to assist the Department of Family Services in making appropriate matches between caregivers and the children placed in their homes. The Placement Teams are responsible for identifying placements for children who require out of home care. The following information is being asked of caregivers so that appropriate matches may be made and children can succeed in their placements. Please consider each factor presented below. In the space provided next to each factor, please indicate whether or not your family would be willing to consider the characteristic being presented. In other words, please tell us what special conditions and characteristics of a child with which you would be willing to work. Checking a box does not necessarily mean that these characteristics will be present in all children placed in your home. Also, please remember that children placed in your home may not display the behaviors indicated in this survey. Please mark only those boxes that apply to your family. Also keep in mind that you are applying to work with higher level of care youth so it is expected that you are willing to consider children with more challenging behaviors.Caregiver InformationName of Primary Caregiver #1 FORMTEXT ?????Name of Primary Caregiver #2 FORMTEXT ?????Name of Non-Primary Caregiver (if applicable) FORMTEXT ????? (separate application required)Schools in your area:Elementary: FORMTEXT ?????Middle: FORMTEXT ?????High: FORMTEXT ?????Child Demographics - Please tell us some basic information about the children you would be willing to accept into your home. Check all that apply.Age FORMCHECKBOX 0-3 FORMCHECKBOX 4-5 (preschool) FORMCHECKBOX 5-11 (grade school) FORMCHECKBOX 12-15 (middle school) FORMCHECKBOX 15-18 (high school)Gender FORMCHECKBOX Female only FORMCHECKBOX Male only FORMCHECKBOX Both Siblings FORMCHECKBOX No sibling groups FORMCHECKBOX 2 children FORMCHECKBOX 3 children FORMCHECKBOX 4 children FORMCHECKBOX 5 children FORMCHECKBOX 6 childrenPlease note that a limit on an age category may limit placement of sibling groups as ages may vary within them.Child’s Special Needs and Considerations - Please tell us if you are able to accept the following special needs and considerations. Marking “Positive” means your family is eager and willing to accept these characteristics; marking “Tentative” means that your family is unsure, but you would consider the placement if given support and/or education. For items that are not applicable, or that you absolutely will not accept, mark N/A. Please do not leave any blanks.Child’s NeedsPositiveTentativeN/AWilling to maintain connections with birth parents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Willing to maintain connections with siblings FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Acceptance of gay/lesbian youth as a placement FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to provide accommodations for a physical disability FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Counseling/therapy/special emotional-behavioral considerations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Acceptance of gender identity confusion/issues FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Acceptance of wheelchair (child ages 2 to 5 years) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Acceptance of wheelchair (child ages 6 and over) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Retain ties with culture and/or religion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Special diet FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Special needs (see below for specific details) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Specialized school FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Special sleeping accommodations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Placement as the only child in the home FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Parents who speak Spanish FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Parents who speak a language other than English or Spanish FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Placement in homes with animals should be avoided FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child Characteristics: Learning/School Issues - Please indicate if your home would be willing to work with and accept the following issues related to learning and school.CharacteristicAcceptCharacteristicAcceptDisruptive in class FORMCHECKBOX Disrespectful to teachers FORMCHECKBOX Low motivation for learning and school FORMCHECKBOX Learning disability FORMCHECKBOX Gifted FORMCHECKBOX Requires special education program FORMCHECKBOX Truancy FORMCHECKBOX School phobia FORMCHECKBOX Child Characteristics: Medical/Emotional Needs and Conditions - The following are issues related to medical, developmental and/or emotional conditions. Please indicate whether or not your family is willing and capable of working with the following conditions. Please remember that in some circumstances, special training might be required in order to work with some of these children.CharacteristicAcceptCharacteristicAcceptAllergies/asthma/nebulizer FORMCHECKBOX Diabetes FORMCHECKBOX Hearing impaired and/or requires signing FORMCHECKBOX Visually impaired and/or requires Braille FORMCHECKBOX Feeding tubes FORMCHECKBOX Limited life span FORMCHECKBOX Needs leg braces, prosthesis, wheelchair FORMCHECKBOX Cerebral Palsy FORMCHECKBOX Seizure disorder FORMCHECKBOX FAS or FAE FORMCHECKBOX Attention Deficit Disorder FORMCHECKBOX Effects of prenatal drug exposure FORMCHECKBOX Developmental disability FORMCHECKBOX Mental retardation FORMCHECKBOX Medically fragile infant FORMCHECKBOX HIV/AIDS FORMCHECKBOX Tracheotomy FORMCHECKBOX Sickle Cell FORMCHECKBOX Down’s syndrome FORMCHECKBOX Muscular Dystrophy FORMCHECKBOX Autism / PDD FORMCHECKBOX Asperger’s Syndrome FORMCHECKBOX Para or quadriplegic (partial assistance required) FORMCHECKBOX Para or quadriplegic (full assistance required) FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other. FORMTEXT ????? FORMCHECKBOX Child Characteristics: Temperament and Behavior - Please tell us if you are able to accept the following temperament and behavior issues. If your family is willing to work with and or accept children with the following temperaments and/or behaviors, please check the appropriate box. For items that are not applicable, or that you absolutely will not accept, please leave blankCharacteristicAcceptCharacteristicAcceptUnusual hunger/eating patterns FORMCHECKBOX Highly argumentative FORMCHECKBOX Unusual sleep patterns FORMCHECKBOX Manipulative FORMCHECKBOX Easily distracted FORMCHECKBOX Abuses animals FORMCHECKBOX Irritable / moody FORMCHECKBOX Hoards food FORMCHECKBOX Uncooperative FORMCHECKBOX Eating disorder FORMCHECKBOX Inflexible FORMCHECKBOX Fearful FORMCHECKBOX Extreme high or low activity level FORMCHECKBOX Stool smearing FORMCHECKBOX High impulsivity FORMCHECKBOX Frequent nightmares FORMCHECKBOX Extreme extrovert FORMCHECKBOX Sleepwalking FORMCHECKBOX Extreme introvert FORMCHECKBOX Excessive sleep FORMCHECKBOX Atypical reaction to new situations FORMCHECKBOX Head banging FORMCHECKBOX Frequent temper tantrums FORMCHECKBOX Daytime or nighttime wetting (age 5-18) FORMCHECKBOX Overtly aggressive behaviors FORMCHECKBOX Depressed affect FORMCHECKBOX Vandalizing or destroying property FORMCHECKBOX Hyperactivity FORMCHECKBOX Talking back / disrespectful to adults FORMCHECKBOX Compulsive or public masturbation FORMCHECKBOX Uses profanity FORMCHECKBOX Sexually seductive or precocious FORMCHECKBOX Smokes FORMCHECKBOX Sexual victimization of other children FORMCHECKBOX Uses drugs / known to use drugs FORMCHECKBOX Explicit sexual language FORMCHECKBOX Fire setting behaviors FORMCHECKBOX Early sexual experimentation FORMCHECKBOX Stealing behaviors FORMCHECKBOX Unusual knowledge or interest in sex FORMCHECKBOX Child Characteristics: Attachment Issues - The following are traits that might be present in a child who has attachment issues. Please indicate if you would be willing to accept a child into your home who might display some of these characteristics.CharacteristicAcceptCharacteristicAcceptHighly ambivalent (indifferent) attachment to birth mom FORMCHECKBOX Compulsive compliance with caregivers FORMCHECKBOX Highly ambivalent (indifferent) attachment to birth dad FORMCHECKBOX Lack of compliance with caregiver requests FORMCHECKBOX Indiscriminate affection with relatively unknown adults – lack of boundaries FORMCHECKBOX Unable to seek or use supportive presence of caregiver FORMCHECKBOX Lack of comfort seeking when frightened, hurt or ill FORMCHECKBOX Failure to check back with caregiver in unfamiliar settings FORMCHECKBOX Excessive dependence on caregiver FORMCHECKBOX Intense anger FORMCHECKBOX Lack of warm and affectionate exchanges FORMCHECKBOX Excessively bossy and controlling FORMCHECKBOX Children placed in your home: Please list only those children currently “placed” in your home, not biological children.1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????5. FORMTEXT ?????6. FORMTEXT ?????Emergency / Disaster PlanEach Licensed Foster Home must have an emergency and disaster plan on file in the licensing department. Please complete one plan for each facility being considered for licensure. Make sure to keep a copy for future use. A new form is required if you relocate to a new residence.Caregiver Name / Facility Name: FORMTEXT ?????Date: FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ????1. EMERGENCIES – LIFE THREATENINGCall 9-1-1, then tell them the number calling fromYour phone #: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Home address: FORMTEXT ?????Major cross streets: FORMTEXT ?????Home Direction from cross street: FORMTEXT ?????2. EMERGENCIES – NON-LIFE THREATENINGList direct local number for the following.Fire/Paramedics: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Child Protective Services: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Physician: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Licensing: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Hospital: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Crisis Center: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Poison Control: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Dentist: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Police/Sheriff: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Other: FORMTEXT ?????: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????3. OTHER EMERGENCY CONTACTSList numbers that may be helpful after a disaster or emergency.Case Worker Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Relative Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Probation Officer Name: FORMTEXT ????? Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Substitute Caregiver Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Other Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????4. HOME EVACUATIONSome emergencies require evacuation of the home. Please review the safest way to exit all rooms in the home. Be sure that exit doors are not locked from the inside. In the event of an emergency, get everyone out; follow the escape routes, meet at a prearranged location and account for everyone. Do not let anyone return to the home until it is safe.5. UTILITY SHUT OFFKnow and record the location of the following utilities:Gas Company Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Electric Company Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Water Company Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????6. EQUIPMENT LOCATIONFire extinguisher location(s): FORMTEXT ?????Smoke alarm location(s): FORMTEXT ?????Fire alarm location(s): FORMTEXT ?????Pool safety equipment location: FORMTEXT ?????Medical First Aid Kit location: FORMTEXT ?????Blankets, outdoor kits location: FORMTEXT ?????Food/Water locations: FORMTEXT ?????Emergency radio location: FORMTEXT ?????7. EMERGENCY BUDDY LOCATIONGive the name and address of the prearranged emergency location where all family members know to go in case of an emergency:Name: FORMTEXT ?????Phone: ( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????Address: FORMTEXT ????? Notes: FORMTEXT ?????DFS Statement of UnderstandingApplicants seeking licensure as an Agency Foster Home are required to read and complete this form.DFS STATEMENT OF UNDERSTANDINGI, FORMTEXT ????? and I, FORMTEXT ????? understand the Department’s primary concern is to find the best possible home for each child, therefore:An application for Foster Care, Adoption or 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 Department has responsibility.If my/our application is approved, I/we are not guaranteed the placement of a child in my/our home.I/we hereby certify the foregoing facts on this application are true and accurate to the best of my/our knowledge. I/we understand that any falsifying of information may result in a denial of this application.__________________________Signature (applicant #1)Date__________________________Signature (applicant #2)DateDFS Statement of AgreementApplicants seeking licensure as an Agency Foster Home are required to read and complete this form.STATEMENT OF AGREEMENTI (We) agree the Department of Family Services cannot issue a Foster Home License nor place children with us without our agreement to the following conditions.I (We) each voluntarily agree:To report to the Department 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.To treat the child or children, whom we may receive in our home, as members of our family.To secure permission of the supervising agency before making plans for taking the child or children out-of-state.To carry out instructions of the supervising agency for care of the child and to cooperate with the Department in maintaining standards.To allow the representative of the Department and/or supervising agency to visit the home. We agree the Department and/or supervising agency may make unannounced home visits.That the Department 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 Department 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 Department to make the most appropriate plan for the child.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.To participate in any required training prior to licensure or re-licensure as scheduled by the Department.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, of which we have received a copy.I (We) have received a signed copy of the statement of agreement for our records._______________________________________________________________________Signature Applicant #1Date_______________________________________________________________________Signature Applicant #2DateI have discussed this statement of agreement with each of the above applicants, as well as those Nevada Foster Care Requirements for which clarification was requested_______________________________________________________________________DFS Licensing RepresentativeDateService AgreementApplicants seeking licensure as an Agency Foster Home are required to read and complete this form.STATEMENT OF AGREEMENTThis is an agreement between _______________________________________ (agency) and ______________________________________________________________(foster/adoptive/ICPC caregiver(s)), for the provision of foster care services to child(ren) placed in their care.Serve as an active member of the service delivery team.The foster/adoptive/ICPC caregiver(s) should:Adhere to the Department’s policy on discipline as defined in the NAC regulation.Participate in case planning conferences, team meetings, and foster care review board meetings, if applicable.Closely observe and document the child’s behavior so that it can be clearly and specifically communicated to the service delivery rm the caseworker of any special needs of the child, including educational, treatment, physical, etc.Encourage the child to communicate with the caseworker.Build a relationship with the primary family of the child to encourage that relationship and facilitate reunification, if called for in the case plan.Encourage visitation between the child and the primary family, if called for in the case plan.Before requesting the removal of a 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.Respect the final decision made by the consensus of the service delivery team.Meet the child’s basic day-to-day needs.The foster/adoptive/ICPC caregiver(s) should:Provide for the child: food, shelter, recreational opportunities, education as required, maintenance of clothing, and transportation, as defined in the case plan.Provide for the child: guidance, discipline, moral instruction, and/or opportunity for religious practices and normally observed holidays and special occasions.Instruct the child in good health and hygiene habits.Respect each child as a unique individual and offer nurturing, loving care, which enhances the child’s positive qualities.Transport and accompany the child to medical and dental appointments.Investigate and encourage the development of the child’s participation in community activities.Assist in preparing the child for transition to the primary family, adoptive family, independent living, or other living arrangements.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.Keep running notes and/or questions of important matters in order to have the most productive discussions with the caseworker at monthly home visits.Develop and maintain a life book for the child to chronicle their life while in substitute care and ensure that it goes with the child to each placement.ConfidentialityThe foster/adoptive/ICPC caregiver(s) should:Respect the confidentiality or information concerning the child 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 rm 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.TrainingThe foster/adoptive/ICPC caregiver(s) should:Complete all pre-service and in-service training as required for licensing.Policies and ProceduresThe foster/adoptive/ICPC caregiver(s) should:Be licensed in accordance with the rules of the Department of Family Services, and comply with all the rules.Adhere to the foster caregiver’s Code of Ethics.Adhere to the Department’s policy on discipline as defined in the NAC regulations.Adhere to the Department’s policy on babysitting. Keep apprised of and adhere to foster care regulations (NAC) and standards.Give the agency adequate notice (i.e., ten (10)) 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.I have read and agree with the contents of this document:_______________________________________________________________________Signature (applicant #1)Date_______________________________________________________________________Signature (applicant #2)Date_______________________________________________________________________DFS Licensing RepresentativeDateRelease of InformationApplicants seeking licensure as an Agency Foster Home are required to read and complete this form.Regarding:Name Applicant #1: FORMTEXT ?????Social Security Number: FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ????Name Applicant #2: FORMTEXT ?????Social Security Number: FORMTEXT ??? - FORMTEXT ?? - FORMTEXT ????You are authorized by the undersigned to release to the Department of 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.Data Requested:_______________________________________________________________________Signature Applicant #1Date_______________________________________________________________________Signature Applicant #2DatePlease return this request to:Agency Licensing UnitDisclosuresIt is mandatory that the following two (2) questions are answered.Child Support Information FORMCHECKBOX I am not subject to a court order for the support of a child. FORMCHECKBOX I am subject to a court order for the support of one or more children and am in compliance with the order, or in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to t he order. FORMCHECKBOX I am subject to a court order for the support of one or more children and am not in compliance with the order, or in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order.Please provide the State, County and City where the Court order was issued: FORMTEXT ?????Total Monthly Payment Obligation $ FORMTEXT ?????Paid Care for Others in the Home FORMCHECKBOX I do not provide regular paid care for others at this time. This includes licensed daycare and any other unlicensed care for others, for which payment is received. This includes anyone living or working in the home, to include care for the elderly, disabled person, or childcare. FORMCHECKBOX I do provide regular paid care for others at this time. This includes licensed daycare and any other unlicensed care for others, for which payment is received. This includes anyone living or working in the home, to include care for the elderly, disabled person, or childcare. An explanation and a copy of my license are attached.Note: We understand that foster parents may not provide care for others, even if another licensing authority does not have a restriction against it. This is to protect the safety of all members of the household and placed children. If provision of such care is verified after a foster care license has been issued, and no administrative waiver has been approved, the foster care license can be revoked.I/We acknowledge that the answers provided above are true and correct.Signature (applicant #1)DateSignature (applicant #2)Date ................
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