Ocfs.ny.gov



NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESEMERGENCY FOSTER HOME APPLICATIONInstructions:Applicant(s): The OCFS-5300A, Emergency Foster Home Application, can be completed by the prospective emergency foster parent(s) or caseworker. The application must be signed and dated by the prospective emergency foster parent(s) and caseworker. PROSPECTIVE EMERGENCY FOSTER PARENT(S) INFORMATIONPROSPECTIVE EMERGENCY FOSTER PARENT #1 LAST NAME: FORMTEXT ?? ???FIRST NAME: FORMTEXT ?????MIDDLE INITIAL: FORMTEXT ?????DATE OF BIRTH: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????Social SEcurity number: FORMTEXT ?????Email Address: FORMTEXT ?????PHONE NUMBER(S): HOME: ( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ????? FORMCHECKBOX N/A CELL: : ( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ????? FORMCHECKBOX N/A CURRENT ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP CODE: FORMTEXT ?????SCHOOL DISTRICT: FORMTEXT ?????MARITAL STATUS: FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Single FORMCHECKBOX Widow/Widower FORMCHECKBOX Separated FORMCHECKBOX Couple Living TogetherDEMOGRAPHICSSEX: FORMCHECKBOX Female FORMCHECKBOX MaleWHAT ARE YOUR PRONOUNS? FORMCHECKBOX She/her/hers FORMCHECKBOX He/him/his FORMCHECKBOX They/them/theirs FORMCHECKBOX Other FORMTEXT ?????GENDER IDENTITY: FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Transgender FORMCHECKBOX Gender non-conforming FORMCHECKBOX Other/Something else FORMCHECKBOX Don’t know FORMCHECKBOX Decline to answerSEXUAL ORIENTATION: FORMCHECKBOX Straight/Heterosexual FORMCHECKBOX Gay or Lesbian FORMCHECKBOX Bisexual FORMCHECKBOX Other/Something else FORMCHECKBOX Don’t know FORMCHECKBOX Decline to answerRACE: FORMTEXT ?????ETHNICITY: FORMTEXT ?????RELIGIOUS AFFILIATION: FORMTEXT ?????LANGUAGES SPOKEN: FORMTEXT ?????NATIVE AMERICAN? FORMCHECKBOX No FORMCHECKBOX Yes If yes, Tribal/Nation Affiliation: FORMTEXT ?????PROSPECTIVE EMERGENCY FOSTER PARENT #2 LAST NAME, FIRST NAME, MIDDLE INITIAL: FORMTEXT ?? ???DATE OF BIRTH: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????Social SEcurity number: FORMTEXT ?????Email Address: FORMTEXT ?????PHONE NUMBER(S): HOME: ( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ????? FORMCHECKBOX N/A CELL: : ( FORMTEXT ?????) FORMTEXT ????? - FORMTEXT ????? FORMCHECKBOX N/A CURRENT ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP CODE: FORMTEXT ?????SCHOOL DISTRICT FORMTEXT ?????MARITAL STATUS: FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Single FORMCHECKBOX Widow/Widower FORMCHECKBOX Separated FORMCHECKBOX Couple Living TogetherDEMOGRAPHICSSEX: FORMCHECKBOX Female FORMCHECKBOX MaleWHAT ARE YOUR PRONOUNS? FORMCHECKBOX She/her/hers FORMCHECKBOX He/him/his FORMCHECKBOX They/them/theirs FORMCHECKBOX Other FORMTEXT ?????GENDER IDENTITY: FORMCHECKBOX Female FORMCHECKBOX Male FORMCHECKBOX Transgender FORMCHECKBOX Gender non-conforming FORMCHECKBOX Other/Something else FORMCHECKBOX Don’t know FORMCHECKBOX Decline to answerSEXUAL ORIENTATION: FORMCHECKBOX Straight/Heterosexual FORMCHECKBOX Gay or Lesbian FORMCHECKBOX Bisexual FORMCHECKBOX Other/Something else FORMCHECKBOX Don’t know FORMCHECKBOX Decline to answerRACE: FORMTEXT ?????ETHNICITY: FORMTEXT ?????RELIGIOUS AFFILIATION: FORMTEXT ?????LANGUAGES SPOKEN: FORMTEXT ?????NATIVE AMERICAN? FORMCHECKBOX No FORMCHECKBOX Yes If yes, Tribal/Nation Affiliation: FORMTEXT ????? OTHER HOUSEHOLD MEMBER(S) INFORMATION(INCLUDE ALL BIOLOGICAL/ADOPTED CHILDREN BUT DO NOT INCLUDE FOSTER CHILDREN UNDER THE AGE OF 18.)*Social Security Number (SSN) is only required for individuals 18 years of age or older.LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????LAST NAME FORMTEXT ????? FIRST NAME FORMTEXT ?????DATE OF BIRTH FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ????RELATIONSHIP TO APPLICANT FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????RELIGION FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SEX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ETHNICITY FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LANGUAGE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MARITAL STATUS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*SSN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? CHILDREN in foster cARE PLACED IN THE HOME INFORMATIONLAST NAME, FIRST NAMEDATE OF BIRTHDATE OF PLACEMENTRELATIONSHIP TO APPLICANT(S) FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?? / FORMTEXT ?? / FORMTEXT ???? FORMTEXT ?????SIGNATURESTo the best of my knowledge, I hereby affirm that the information provided above is true and complete.PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE:XDATE: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE:XDATE: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????CASEWORKER’S SIGNATURE:XDATE: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????PROSPECTIVE EMERGENCY FOSTER PARENT #1 SWORN STATEMENT Prospective Emergency Foster Parent #1: Complete, sign, and date this statement. LAST NAME: FORMTEXT ?????FIRST NAME: FORMTEXT ?????MIDDLE NAME: FORMTEXT ?????MAIDEN NAME OR ANY OTHER ALIAS: FORMTEXT ?????CURRENT MAILING STREET ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP CODE: FORMTEXT ?????Have you ever been convicted of a crime within New York State or any other jurisdiction or state? FORMCHECKBOX No FORMCHECKBOX YesIf yes, provide an explanation for each crime for which you were convicted of, including the type of crime, the location, the date and circumstances: FORMTEXT ?????Has any person age 18 or older currently residing in the home ever been convicted of a crime within New York State or any other jurisdiction or state? FORMCHECKBOX No FORMCHECKBOX YesIf yes, provide an explanation for each crime for which the person(s) was/were convicted of, including the type of crime, the location, the date and circumstances: FORMTEXT ?????To the best of my knowledge, I hereby affirm that the information provided above is true and complete. I understand that the information is subject to verification and that making a materially false statement or affirmation may result in disqualification as an applicant for deliberately presenting false or misleading information.PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE:XDATE: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ?????PROSPECTIVE EMERGENCY FOSTER PARENT #2 SWORN STATEMENT Prospective Emergency Foster Parent #2: Complete, sign, and date this statement. LAST NAME: FORMTEXT ?????FIRST NAME: FORMTEXT ?????MIDDLE NAME: FORMTEXT ?????MAIDEN NAME OR ANY OTHER ALIAS: FORMTEXT ?????CURRENT MAILING STREET ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP CODE: FORMTEXT ?????Have you ever been convicted of a crime within New York State or any other jurisdiction or state? FORMCHECKBOX No FORMCHECKBOX YesIf yes, provide an explanation for each crime for which you were convicted of, including the type of crime, the location, the date and circumstances: FORMTEXT ?????Has any person age 18 or older currently residing in the home ever been convicted of a crime within New York State or any other jurisdiction or state? FORMCHECKBOX No FORMCHECKBOX YesIf yes, provide an explanation for each crime for which the person(s) was/were convicted of, including the type of crime, the location, the date and circumstances: FORMTEXT ?????To the best of my knowledge, I hereby affirm that the information provided above is true and complete. I understand that the information is subject to verification and that making a materially false statement or affirmation may result in disqualification as an applicant for deliberately presenting false or misleading information.PROSPECTIVE EMERGENCY FOSTER PARENT’S SIGNATURE:XDATE: FORMTEXT ????? / FORMTEXT ????? / FORMTEXT ????? ................
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